Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns (D6740) and a pontic (D6245) provided on 
June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not have a choice in choosing 
porcelain/ceramic and you were told by the Plan's representative that you should be reimbursed for the cost of 
metal crowns. The Plan denied your request. The Plan says the procedures are not a covered benefit under the 
dental plan. 
 
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 pay for retainer 
crowns (D6740) and a pontic (D6245) provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on March 
28, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of acute respiratory failure. The 
review has determined that the records do not support the use of J96.01 - acute respiratory failure with hypoxia 
- in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee is not part of a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 18, 2017, the Centers for 
Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence 
Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services rendered on April 24, 2022. 
 
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 that evaluation and management codes are not covered for this specialty or provider 
type. 
 
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. The Plan states that billed evaluation and management code 99291 is not 
covered for this specialty or provider type.  The file shows that the services were provided by a physician. 
There is no documentation or Medicare rules provided to support that the code is not payable as billed. 
Therefore, we decided that the Plan has to pay for the critical care services rendered on April 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 12, 2022 to 
August 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from July 12, 2022 to August 
10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental of a continuous positive airway 
pressure (cpap) device (E0601) and humidifier (E0562). 
 
You asked the Plan to pre-approve continued rental of a cpap and humidifier. You say that you were not aware 
how often you needed the mask. You will visit your prescribing provider next month. The Plan denied your 
request. The Plan says you must have a face-to-face evaluation with your ordering provider between 31 and 91 
days after starting CPAP therapy with documentation showing that your symptoms of sleep apnea have 
improved. You have not been seen by your provider following your CPAP use. Additional criteria states that 
you must be using your CPAP at least 4 hours every night for at least 70% of nights during consecutive 30 days 
anytime over 3 months. You have used your CPAP only 43% for at least 4 hours over 3 months. You do not 
meet this criterion. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that you must use your cpap device 4 hours per 
night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of 
initial usage. Medicare rules also say that the treating practitioner must conduct a clinical re-evaluation and 
document that the beneficiary is benefiting from PAP therapy. The records show that you are not meeting the 
minimum requirement of usage for your cpap device, and you have not had a re-evaluation with your treating 
provider. Based on this information, we decided that Medicare rules for coverage of continued rental of a 
CPAP and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continued rental of a continuous positive airway pressure (cpap) device (E0601) and humidifier (E0562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a four-week trial using a basic device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no documentation that the enrollee has had a four-week trial using a pneumatic 
compression device without calibrated gradient pressure that showed no significant improvement in her 
symptoms. The enrollee does not have unique characteristics that would indicate the segmented pump over a 
standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550, 99156, and 99157 billed for date of 
service May 5, 2021. 
 
You asked the Plan to pay for procedure codes A4550, 99156, and 99157. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 
99156, and 99157 are column II codes to column I code 64493. This claim has not been billed with an 
appropriate modifier to bypass the edit. Code A4550 has a status indicator of "B" and cannot 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 procedure codes A4550, 99156, and 99157 billed for date of service May 
5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up (E1399). 
 
You asked the Plan to pre-approve a battery back-up. You say that the enrollee has a critical issue with his 
power. The Plan denied your request. The Plan says the service/item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery back-up (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next continuous glucose monitor test strips. 
 
You asked the Plan to pre-approve Contour Next continuous glucose monitor test strips. You say that you have 
been using this brand for the past six years and have been successfully managing your Type 2 Diabetes with 
this product The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
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 brand in this case is not a preferred brand with the Plan. The Plan has preferred brands available 
that can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items. Therefore, we decided that the Plan does not have to pre-approve Contour Next 
continuous glucose monitor test strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to April 
13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that the requested use of Gammagard is medically 
necessary. The Plan denied your request. The Plan says the requested use of Gammagard is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 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 Gammagard. Our reviewer says that the 
requested use of Gammagard is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of myasthenia gravis. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendium, 
DrugDex indicates that evidence favors efficacy of the requested drug for the enrollee's condition. However, 
the documents provided do not indicate that the enrollee has severe disease and that the requested drug is being 
used to treat acute severe decompensation when other treatments have been unsuccessful or are contraindicated 
in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory suction pump (E0600). 
 
You asked the Plan to pre-approve a respiratory suction pump. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory suction pump (E0600) is only 
covered for beneficiaries who have difficulty raising and clearing secretions secondary to cancer or surgery of 
the throat or mouth, dysfunction of the swallowing muscles, unconsciousness or obtunded state, or 
tracheostomy. Use of a respiratory suction pump for other conditions will be denied as not reasonable and 
necessary. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has 
difficulty raising and clearing secretions secondary to cancer or surgery of the throat or mouth, dysfunction of 
the swallowing muscles, unconsciousness or obtunded state, or tracheostomy. Based on this information, we 
decided that Medicare rules for coverage of a respiratory suction pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a respiratory suction pump (E0600).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel (87529, 87481, 87556, 
87491) provided on August 2, 2022. 
 
You asked the Plan to pay for the urinary tract infection panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the testing is not FDA approved nor has the testing 
undergone registration with Molecular Diagnostic Services Program (MolDX). 
 
The Plan must follow Medicare rules. Medicare rules say that infection disease panels must have FDA approval 
and registration with MolDX and a TA. 
 
We looked at the file and Medicare rules. This testing is not FDA approved. Based on this information, we 
decided that Medicare rules for coverage of the urinary tract infection panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the urinary tract infection panel (87529, 87481, 87556, 87491) 
provided on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 3, 2022. 
 
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 modifier 59 is not appropriate as the records do not support a separate and distinct lab service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided to the enrollee on June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 26, 2021, to December 28, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the determination to remove diagnosis code 
A41.9 was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. The review has 
determined that the records did not support the use of diagnosis code A41.9 - sepsis, unspecified organism - in 
this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 26, 2021, to December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 26, 2022, billed with 
codes 81225, 81226, 81227, 81401, 81230, 81231, 81240, 81241, 81328, 81335 and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical records. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 26, 2022, billed with codes 81225, 81226, 81227, 81401, 81230, 81231, 81240, 81241, 81328, 81335 and 
81291.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) surgery. 
 
You asked the Plan to pre-approve TKA surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the record does not show the enrollee's knee has a significant amount 
of breakdown or is deformed. 
 
The Plan follows Medicare rules. Medicare rules state that total knee arthroplasty surgery may be covered if 
certain criteria are met. 
 
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 TKA surgery. Our reviewer says that 
the enrollee does not meet the Medicare criteria for TKA surgery. Our physician reviewer found the 
documentation is not evident regarding a trial and failure of recent, reasonable, and comprehensive less-
invasive conservative care measures including injections. Additionally, formal imaging studies are not 
provided to corroborate the pathology in the right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TKA surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total knee arthroplasty (TKA) surgery.