Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external insulin infusion pump and supplies (A4230, 
A4225, E0784). 
 
You asked the Plan to pre-approve the external insulin pump. You say that you are on a carbohydrate diet and 
do not eat sweets. You also say that you have done everything your doctor recommended you do and he agreed 
you need this pump and supplies. The Plan denied your request. The Plan says you do not require insulin three 
or more times daily. 
 
The Plan follows Medicare rules. Medicare rules say that you must have been on a program of multiple daily 
injections of insulin (at least 3 injections per day) with frequent self-adjustments of insulin dose for at least 6  
months prior to initiation of the insulin pump and has documented frequency of glucose self-testing an average 
of at least 4 times per day during the 2 months prior to initiation of the insulin pump. 
 
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 external insulin pump. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the nephrologist documents that 
your diabetes is not managed appropriately by your primary care physician. You take 16u of Novolog 75/25 
with one meal daily, and then 26u of Tresiba at bedtime with a snack. You reported that you bottom out 
frequently with blood sugars in the 20s and 30s, and sometimes passes out. You are concerned about this and 
requested a DexCom6 to monitor your blood glucose more effectively. 
  
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 external insulin pump and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external insulin infusion pump and supplies (A4230, 
A4225, E0784).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show an absence of other sources of pain. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the imaging studies show spondylolysis as another cause of the back pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of implant; deep (eg, buried wire, pin, screw, metal 
band, nail, rod or plate) rendered on June 22, 2022. 
 
You asked the Plan to pay for the surgery. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 20680 remains not supported. 
 
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 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)." 
 
We asked our coder 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 the surgery. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there was no indication of any 
hardware in the right foot. Moreover, the procedure in detail corroborated the bones were shaved at the 
proximal interphalangeal joints of the second, third, and fourth digits. Therefore, the records do not support the 
use of CPT 20680.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) rendered 
on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental prophylaxis (cleanings)-(D1110) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental prophylaxis (cleanings)-(D1110). You say that you had your first 
cleaning on April 5, 2022, and the next cleaning was on October 11, 2022, which is more than 6 months after 
the first cleaning for the Plan year 2022. The Plan denied your request. The Plan says that the reported service 
is limited to 2 in a 12 consecutive month period. 
 
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. The Plan covers the dental 
prophylaxis (cleanings)-(D1110) 1 every 6 months. 
 
We looked at the file and the Plans rules. The file shows that the cleanings were provided within the 
timeframe under the Plan benefit. Based on this information, we decided that the Plan's rules for coverage of 
the dental prophylaxis (cleanings)-(D1110) have been met. Therefore, we decided that the Plan has to pay for 
dental prophylaxis (cleanings)-(D1110) provided on October 11, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physician office visit (99214) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a physician office visit. You say that you are an established patient with the 
provider at issue. The Plan denied your request. The Plan says rules for coverage for OON services have not 
been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a physician office visit (99214) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on September 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial of the claim and have submitted medical records for review. The Plan denied your request. The 
Plan says pneumatic compression devices are not covered by Medicare when the place of service is an 
ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 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 place of service billed was 24, which is an 
ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, it must be 
appropriate and be needed for use inside the home. Medicare does not consider an ambulatory surgical center a 
home, therefore, the requested items are not covered. Therefore, we decided that the Plan does not have to pay 
for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg 
(E0673) provided on September 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that based on 
the available records the enrollee appears to have improved with therapy to the point of being able to ambulate 
300 to 400 feet with a rolling walker with stand-by assistance and is contact guard to stand-by assist for 
transfers. After the provided physical therapy treatments, the records do not support that the complexity of the 
enrollee's conditions are such that the skills of a professional therapist are required to achieve further 
improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program 
appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
September 26, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on September 26, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of pain is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from September 4, 2022, to September 5, 2022. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 99233 (1 Unit) remains not 
supported. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the medical records 
submitted did not support a detailed interval history and medical decision making of high complexity. Two out 
of the three key components were not met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered from September 4, 2022, to 
September 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
January 10, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group (code G2067). You say that you have 
been enrolled in the Medicare program to provide Opioid Treatment Program (OTP) services since  
January 01, 2020. The Plan denied your request. The Plan says that this code must be billed by the OTP facility 
on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on January 10, 2022.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic shoes (A5500) and inserts (A5514). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of the 
requested items. 
 Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. Additionally, Medicare rules say that therapeutic 
shoes, inserts and/or modifications to therapeutic shoes are covered if all criteria are met. The Plan follows 
these same rules.   
 
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 requested items. Our reviewer says 
that the enrollee meets criteria for coverage of the requested items. Our physician reviewer found that a 
certificate of medical necessity was filled out by the enrollees physician stating that he has diabetes, has a 
history of peripheral neuropathy with evidence of callous formation, and is being treated under a 
comprehensive plan of care for diabetes. This form also advises that the enrollee is in need of diabetic shoes 
and insoles. The enrollee was recently seen by his primary care physician on January 18, 2023. Medicare 
guidelines for therapeutic shoes and inserts require that the patient must be a diabetic, must have had either a 
previous amputation of the other foot or part of either foot, or history of previous foot ulceration of either foot, 
or history of a pre-ulcerative callous of either foot, or peripheral neuropathy with evidence of callous formation 
of either foot, or foot deformity of either foot, or poor circulation in either foot. The certificate of medical need 
filled out for this enrollee meets the above-mentioned criteria. Therefore, the enrollee does meet criteria for 
coverage of the requested items. 
 
We looked at the physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested items have been met. Therefore, we decided that the Plan has to 
pre-approve diabetic shoes (A5500) and inserts (A5514).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3.  
You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz FX is required before alternatives can be considered. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatric diagnostic evaluation. 
 
You asked the Plan to pre-approve a psychiatric diagnostic evaluation. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this provider is not a Medicare-approved provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor and a 
Marriage Family Therapist are not eligible to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor and a Marriage Family Therapist. Medicare says that a Licensed Professional Counselor and a 
Marriage Family Therapist are not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pre-approve a psychiatric diagnostic evaluation.