Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for extracorporeal photopheresis (36522) provided on November 17, 2021. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that the requested service was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for payment 
for the requested service have not been met. 
 
The Plan must follow Medicare rules. The rules say that extracorporeal photopheresis is reasonable and 
necessary under the circumstances listed in the Medicare rules section.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for extracorporeal photopheresis. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has been receiving apharesis since 2018 with response. The service at issue is a 
continuation from 2018 and continuation must be approved per Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have been met. Therefore, we decided that the 
Plan has to pay for extracorporeal photopheresis (36522) provided on November 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee appears to be at/near a new plateau in 
function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device.
You asked the Plan to pre-approve intermittent limb compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation of the response to a 4 week trial of conservative therapy.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary and with a four-week trial of conservative therapy demonstrating failed response to treatment is required. The file does not show a 4-week trial of conservative therapy including pre and post-trial measurements. Therefore, we decided that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need to get to medical 
appointments and have no other transportation. The Plan denied your request. The Plan says you have utilized 
the maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), problem focused 
detailed and extensive oral evaluation (D0160), complete series of intraoral x-rays (D0210), two-dimensional 
(2D) oral/facial photographic image (D0350), cone beam computed tomography (CT) capture and 
interpretation (D0367), and diagnostic casts (D0470) provided on November 20, 2019. 
 
You asked the Plan to pay for the comprehensive oral evaluation, problem focused detailed and extensive oral 
evaluation, complete series of intraoral x-rays, 2D oral/facial photographic image, cone beam CT capture and 
interpretation, and diagnostic casts. The Plan denied your request. The Plan says this claim was received past 
the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the comprehensive oral evaluation, problem focused detailed and extensive 
oral evaluation, complete series of intraoral x-rays, 2D oral/facial photographic image, cone beam CT capture 
and interpretation, and diagnostic casts was not filed until November 23, 2021. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150), problem focused detailed and extensive 
oral evaluation (D0160), complete series of intraoral x-rays (D0210), two-dimensional (2D) oral/facial 
photographic image (D0350), cone beam computed tomography (CT) capture and interpretation (D0367), and 
diagnostic casts (D0470) provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested equipment is 
medically necessary. The Plan denied your request. The Plan says you have swelling of the legs, and you do 
not have swelling in your abdomen and/or chest. The specific device ordered by your doctor is approved only 
for swelling that goes into the abdomen and/or chest. The Plan also says that the rules state specifically that this 
device is not covered for swelling of the legs only. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), additional periapical x-ray (D0230), pulp vitality test (D0460), and cone beam CT capture with 
interpretation (D0364) provided on February 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that a plan representative advised your policy was 
not in effect until May 16, 2021. You say that it is your understanding that your dental policy was in effect as 
of January 1, 2021. You also say that you have had this policy for 2 years. The Plan denied your request. The 
Plan says the services you received are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services you received are not 
among those covered under this benefit. Additionally, the record shows that you were not enrolled in the 
enhanced dental plan on the date of service in this case. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140), periapical x-ray (D0220), additional periapical x-ray (D0230), pulp 
vitality test (D0460), and cone beam CT capture with interpretation (D0364) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and deep 
sedation/general anesthesia services (D9222 and D9223) provided on September 17, 2020. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue and deep sedation/general anesthesia services. 
The Plan denied your request. The Plan says the incisional biopsy of oral tissue is not a covered benefit. The 
Plan also says that when the primary procedure is not covered by Medicare, the administration of anesthesia is 
also not covered by Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incisional biopsy of oral tissue (D7286) and deep sedation/general anesthesia services (D9222 and D9223) 
provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve the insertion of a subcutaneous cardiac rhythm monitor. You say that the 
records provided support the need for the requested monitor. The Plan denied your request. The Plan says a 
medical need for an implantable loop recorder has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the insertion of a subcutaneous cardiac rhythm monitor is not 
considered medically reasonable and necessary in this case. Our physician reviewer found, while the enrollee 
has a history of atrial fibrillation, there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for the insertion of a subcutaneous cardiac rhythm 
monitor. There is insufficient documentation to support the medical necessity for the insertion of a 
subcutaneous cardiac rhythm monitor in this enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a subcutaneous cardiac 
rhythm monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar medial branch block services. 
 
You asked the Plan to pre-approve lumbar medial branch block services. You say that the enrollee had the 
same procedure on January 10, 2022, with positive relief and would like to have the repeat injection as soon as 
possible. You say that the enrollee is in extreme pain and that the chart notes support the need for the requested 
services. The Plan denied your request. The Plan says the requested injection services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are covered when 
medically reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar medial branch block services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
underwent a right L4 medial branch block (MBB) and L5 dorsal ramus block on February 14, 2022, and 
reported 0% pain relief post procedure. The requested injection services are considered not medically 
reasonable and necessary in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar medial branch block services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar medial branch block services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures (D5120, D5110). 
 
You asked the Plan to pre-approve dentures. You say that dentures are the only thing that can help you. The 
Plan denied your request. The Plan says dentures are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dentures (D5120, D5110).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Rhythm electrocardiogram (93042) provided on 
September 1, 2021. 
 
You asked the Plan to pay for code 93042. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Rhythm electrocardiogram (93042) provided on September 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bonding of a supported crown (D6092) 
provided on October 22, 2021. 
 
You asked the Plan to pay for the crown service. You say that this is an in-network provider, and this service 
should be covered. The Plan denied your request. The Plan says this service is not covered by your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bonding of a supported crown (D6092) provided on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zilretta injection provided on June 3, 2020. 
 
You asked the Plan to pay for Zilretta injection. You say that the injection was medically necessary. The Plan 
denied your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Zilretta injection. Our reviewer says that the 
Zilretta injection was not medically necessary. Our physician reviewer found Zilretta is not intended for repeat 
administration. The reviewer found that the documentation does not support that the Zilretta is medically 
reasonable and necessary for the enrollee. The reviewer also found that the documentation does not support that 
the Zilretta is safe and effective for the enrollee. 
 
 
 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injection have not been met. Therefore, we decided that the Plan does 
not have to pay for Zilretta injection provided on June 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(99239) provided on August 9, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that these services are supported as 
billed. The Plan denied your request. The Plan says the medical records do not support that a hospital discharge 
day management of more than 30 minutes were performed. The records do not include the time spent providing 
this service. Therefore, this code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. It cannot be verified that more than 30 minutes were spent providing this 
service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (99239) provided on August 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that Eylea 
(J0178) is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Bevacizumab before they will approve the requested drug. Our reviewer found that you have tried and failed 
the required drug. Our physician reviewer also found that the documentation does not support that Eylea 
(Aflibercept) would likely be less effective, and/or would likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient is a 70-year-old male who was admitted to the acute care hospital for 
ventricular fibrillation and acute respiratory failure requiring cardiopulmonary resuscitation, epinephrine, and 
was diagnosed with diffuse multivessel cardiovascular disease, mechanical ventilation support, Zoll Life Vest 
(not appropriate for coronary artery bypass graft surgery (CABG) due to mental status), and antibiotics for 
pneumonia/bacteremia. The course was complicated by gastrointestinal bleed, and chronic kidney failure.  
 Recent notes describe the patient as sill requiring vent support, Precedex, Norepinephrine, and plans for CABG 
as outpatient were being made. The patient appears to be improving but is still somewhat unstable (sedation, 
vasopressor need) and requires short-term additional acute care services that can safely be administered at the 
current facility until more stable and appropriate for a lower level of care. The patient does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as the patient is still unstable and as it would not be clinically advantageous. Transfer may 
be considered when treatment has completed and the patient is more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.