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

 
We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested electronic connection 
exceeds the enrollee's medical need. He has two power options on the approved power wheelchair but his upper 
extremity function with independence in eating supports that he can control any power options through their 
own switches. The electronic connection is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery services. 
 
You asked the Plan to pre-approve the oral surgery. You say that you had a tumor in the femur. You say that 
your femur and hip were replaced with metal hardware. You say that if tissue nearby gets infected due to an 
infection from the mouth, it could be life threatening. The Plan denied your request. The Plan says the 
requested oral surgery is not a covered benefit. 
 
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 oral 
surgery services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive electrophysiologic evaluation (93620) and 
intraventricular pacing (96312) provided on January 2, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says the claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 codes 
93620 and 93612 are both column II codes to column I code 93653. This claim has a modifier indicator of 0 
indicating that modifiers are not appropriate and these codes will not be paid separately. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for comprehensive electrophysiologic evaluation (93620) and intraventricular pacing (96312) provided on 
January 2, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on February 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this service is not 
allowed as it is included in the skilled nursing facility consolidated billing. 
 
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. In this case, the ambulance transported the enrollee to the skilled nursing facility 
after he was discharged from the hospital. This is a separately reimbursable service. Additionally, the Plan 
didnt submit any evidence that the enrollee was in a Part A covered stay. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the ambulance 
services provided on February 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
October 29, 2021. 
 
You asked the Plan to pay for the dental photographs. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says they have agreed to pay for the crown, but the dental 
photographs are 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 2D 
oral/facial photographic images (D0350) provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for a continuous glucose 
monitor (CGM). 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit rendered on September 18, 
2021. 
 
You asked the Plan to waive the cost sharing for these services. You say that the services were an annual 
wellness exam and should have no copayment. The Plan denied your request. The Plan says the cost sharing 
was applied correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $250 combined in-network and out-of-network medical deductible 
which applies to your covered medical services and a 20% coinsurance for services obtained from a primary 
care provider. 
 
The item or service you asked the Plan to waive the cost sharing for falls within the services obtained from a 
primary care provider benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $250 combined in-network and out-of-network medical deductible which applies to your 
covered medical services. This cost sharing is a contractual obligation that had not been met at the time these 
services were received on September 18, 2021.  
 
The records show that you were seen for a wellness exam but also had a follow up for hyperlipidemia during 
this visit. These services fall outside of the scope of the annual wellness exam. The Plan applied $76.68 toward 
your deductible for these services. At this time, your deductible was met. Given that the deductible did not 
cover the entire charge of the services you have also been asked to pay a 20% coinsurance on the remaining 
amount, for a total of $.33. The total amount you have been asked to pay for these services is $77.01.  
 
Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit rendered on 
September 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (37249, 37252, 37253, 75822) provided
July 1, 2021.
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 37249, 37252, 37253, & 75822 are not supported in the medical record. Specifically,
the operative report does not support that procedure codes 37249, 37252, & 37253 were performed. The record
does not show that CPT 75822 was a separate procedure from the thrombectomy performed. Based on this
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore,
we decided that the Plan does not have to pay for surgical services (37249, 37252, 37253, 75822) provided July
1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex Faspro for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no record of a trial of the preferred 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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the provided records do
not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not
indicate that the enrollee has neuropathy nor that dose adjustment would not be effective if neuropathy were to
develop. The record does not indicate that the enrollee has a contraindication to, or would have an adverse
effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Darzalex Faspro for the enrollee.
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's functional level did not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF during the dates January 31, 
2022  February 22, 2022 as it was near baseline. The enrollee did not require skilled nursing or skilled therapy 
services, or a combination of these services, on a daily basis in a SNF during the dates in question. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided September 11, 
2021. 
 You asked the Plan to pay for the hospital services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says payment for this service was 
included in the global surgical package. 
 
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 99232 
is a column II code to column I code 36556. The initial evaluation 99232, is included when billed the same day 
as minor surgery procedure (36556). 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 subsequent hospital care (99232) provided September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on February 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99100 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from August 3, 
2021, to August 20, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed are not covered under the chiropractic benefit and 
the enrollee did not have prior authorization. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the service at issue is not manual manipulation of the spine. The records show the 
enrollee did not have prior authorization. Therefore, we decided that the Plan does not have to pay for 
chiropractic services provided to the enrollee from August 3, 2021, to August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 in this case the enrollee was admitted with acute hypoxic respiratory failure in the setting cholangiocarcinoma. The record indicates that the enrollee has had a prolonged and complicated hospital course and still requires ongoing acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 5, 2020, to March 23, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
We find that the services are not supported in the medical record. Specifically, the claim was billed for 18 days. 
As 3/22/20 is not a billable day, this was not reported correctly. 
 
Additionally, the records do not reflect two required skin treatments, as is needed with the score that was 
reported in this case. There does appear to be documentation of turning/positioning and skin treatment, they are 
outside of the five-day lookback period.  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 skilled 
nursing facility (SNF) services provided to the enrollee from March 5, 2020, to March 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on February 27, 2022 with left hip pain. You had a non-healing incision site from surgery in November of 2021. The therapy note dated March 8, 2022 states you are walking eight feet with a walker and assistance. The surgical incision was healed and you were instructed to follow up with your surgeon per the March 8, 2022 progress note. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging and surgical services rendered on February 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 75716 and 36140 are not separately payable. 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 75716 (bilateral extremity angiography), 36140 
(introduction of needle or intracatheter, upper or lower extremity artery), and 37229 (endovascular 
revascularization). Codes 75716 and 36140 are column II codes with a modifier indicator of 1 when billed with 
column I code 37229. The column II codes were not billed with an appropriate modifier to allow for separate 
payment. The records do not support the billing of the -59 modifier as a separate and distinct procedural 
service. Therefore, we decided that the Plan does not have to pay for the imaging and surgical services 
rendered on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for guided tissue regeneration (D4266), a surgical extraction (D7210), bone replacement graft (D7953) and drugs or medicaments dispensed in the office for home use (D9630) provided on May 17, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered under your medical benefit. The Plan denied your request. The Plan says these services are 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 guided tissue regeneration (D4266), a surgical extraction (D7210), bone replacement graft (D7953) and drugs or medicaments dispensed in the office for home use (D9630) provided on May 17, 2021.