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

 
We decided that the Plan does not have to pay for the anesthesia services (00811) provided on September 29, 
2022. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says payment is 
included in another service. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia codes describe a general anatomic 
area or service which usually relates to a number of surgical procedures, often from multiple sections of the 
CPT Manual. For Medicare purposes, only one anesthesia code is reported unless the anesthesia code is an 
Add-on Code (AOC).  
 We looked at the file and Medicare rules. In this case, anesthesia code 00811 is not payable. Payment for this 
service is included in the payment for code 01482 provided on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services (00811) provided on 
September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services for an outpatient visit provided on 
August 30, 2022. 
 
You asked the Plan to pay for the nurse practitioner services for an outpatient visit. You say that you had a left 
ear infection treated prior to leaving for vacation. You say that while on vacation, you wanted to get your right 
ear examined and went to this walk-in clinic as urgent care. You say they examined your ear and suggested 
using the ear drops on your right ear. The Plan denied your request. The Plan says this provider is ineligible 
because per the North Dakota license portal the providers license was expired.  
 
The Plan must follow Medicare rules. Medicare rules say that in order to furnish covered NP services, an NP 
must be a registered professional nurse who is authorized by the State in which the services are furnished to 
practice as a nurse practitioner in accordance with State law.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nurse practitioner services for an outpatient visit have not been met. Therefore, we decided that 
the Plan does not have to pay for nurse practitioner services for an outpatient visit provided on  
August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is a patient under your care for 
management of severe restrictive lung disease and severe COPD resulting in chronic respiratory failure since 
contracting Covid. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in TTV-VAPS mode with Auto-EPAP(AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 provided on February 8, 2022. 
 
You asked the Plan to pay for procedure code 99236. You say that the medical records support the billing of 
code 99236 provided on February 8, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99236 provided on February 8, 2022. 
 
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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) requiring admission are of high severity. Typically, 55 
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 procedure code 99236. Our reviewer says that the medical 
records do not support the billing of code 99236 provided on February 8, 2022. Our reviewer found procedure 
code 99236 can be used for subsequent observation care, per day, for the evaluation and management of a 
patient. The code can be used if the evaluation and management of a patient requires 3 key components 
including a comprehensive history, a comprehensive physical examination and medical decision making of 
high complexity. Usually, the presenting problems are of high severity and require urgent evaluation by a 
medical provider but do not pose an immediate significant threat to life or physiologic function. Counseling 
and/or coordination of care with other medical providers or agencies are provided consistent with the nature of 
the problem and the patients and/or familys needs. In this case, the documentation does not support procedure 
code 99236. The documentation available for review does not support that the presenting problems were of 
high severity or that the medical decision making was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99236 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration stating 
medically necessary and failure to adequately treat the enrollee with non-invasive ventilation could result in 
increased hospitalizations, serious harm, or death due to elevated CO2 levels. The Plan denied your request. 
The Plan says the records do not show that the requested device will not be used exclusively in bi-level PAP 
mode. The ventilator was ordered in a mode called volume assured pressure support (VAPS), and this can be 
achieved with bi-level devices such as a BiPAP machine. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode with auto-titration (AE) which could be provided by a BiPAP device with average volume assured 
pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD 
policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy Tab 100 mg. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the enrollee continues to experience 
unremitting migraines on a weekly basis with greater than 15 headache days each month. The Plan denied your 
request. The Plan says Ubrelvy is a self-administered drug, and the medication does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy Tab 100 mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor (A9276). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the requested sensor is not eligible for 
Medicare 
coverage under the durable medical equipment (DME) benefit because it is not classified, nor used with 
equipment classified, as DME. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 sensor (A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) and odontoplasty 
(D9971). 
 
You asked the Plan to pre-approve the dental services. You say that you need the mandibular partial denture 
because you are not able to eat. The Plan denied your request. The Plan says these services are either not 
covered under your dental plan or your benefit for the requested item or service has been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for D5214 was exhausted on date of service September 10, 2019. Additionally, D9971 is 
not covered under any circumstance. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (D5214) and odontoplasty (D9971).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost-sharing amounts applied to a resin-based composite - 
two surfaces, posterior tooth #13 (D2392), amalgam - three surfaces, primary or permanent tooth #12 (D2160), 
and amalgam - four or more surfaces, primary or permanent tooth #15 (D2161) provided on September 1, 
2022. 
 
You asked the Plan to adjust the cost-sharing amounts applied to the dental services represented by codes 
D2392, D2160, and D2161. You say that you were unaware of the cost differences in the services. You also say 
that the doctor recommended this based off the images. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Class 2 Basic services. You contract with the Plan also says that when a less expensive 
alternate procedure would be satisfactory, the maximum allowed will be the charge for the less expensive 
treatment.  
 
You have been asked to pay $262.20 in total. This included a 20% coinsurance for code D2392 ($38), a 20% 
coinsurance for code D2160 ($32.80) and a 20% coinsurance for code D2161 ($39.40). This also included the 
difference between the cost of the more expensive procedures billed and the less expensive alternative 
procedures allowed. The allowed amount for billed code D2393 was $231. The less expensive alternative the 
Plan paid for (D2160) had an allowed amount of $164. The difference between the two is $67. The allowed 
amount for billed code D2394 was $282. The less expensive alternative the Plan paid for (D2161) had an 
allowed amount of $197. The difference between the two is $85.  
 
These services fall within the fillings Class 2 Basic services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to adjust the cost-sharing amounts applied to a resin-based composite - two surfaces, posterior tooth #13 
(D2392), amalgam - three surfaces, primary or permanent tooth #12 (D2160), and amalgam - four or more 
surfaces, primary or permanent tooth #15 (D2161) provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided do not support the rationale for this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time 
cardiac catheterization would not be considered medically appropriate and necessary 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 3D rendering with interpretation and reporting of 
computed tomography, MRI, ultrasound, or other tomographic modality with image postprocessing under 
concurrent supervision; requiring image postprocessing on an independent workstation (76377). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no biopsy planned and 3D Picture scan of MRI is being done to 
assess response to hormone therapy only. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found they do not see radiation or surgery complete. Our physician review does not see follow up 
prostate-specific antigen (PSA). Our physician reviewer states the 3D MRI is not medically necessary at this 
time; however, 3D MRI can be considered later after all treatment is completed and if the PSA is still elevated. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the 3D rendering with interpretation and reporting of computed tomography, MRI, 
ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring 
image postprocessing on an independent workstation (76377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76942-59) provided on June 2, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 radiology services Our reviewer says that 
the documentation provided does not support that the billed code is separately payable. Our physician reviewer 
found ultrasonic guidance would be included in the arthrocentesis procedure. Documentation does not support 
a separate procedure. 
 
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 radiology services have not been met. Therefore, we decided that the Plan 
does not have to pay for radiology services (76942-59) provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on August 10, 2022, 
August 15, 2022, and August 23, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you have not been fully reimbursed for 
your dental annual maximum. The Plan denied your request. The Plan says your annual dental maximum 
benefit for the year has already been exhausted. 
 
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, certain limitations apply. On February 
8, 2022, the Plan paid $138 for dental services. On May 25, 2022, the Plan paid $62 for dental services. For the 
year of 2022 the Plan paid $200 ($138 paid + $62 paid) for dental services; therefore, your annual dental 
maximum benefit for the year was exhausted on the date of service of May 25, 2022. Therefore, we decided 
that the Plan does not have to pay more for the dental services provided on August 10, 2022, August 15, 2022, 
and August 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 Plan has not provided enough evidence to support the denial of 
payment for the laboratory services provided based on Medicare criteria. Therefore, we decided that the Plan 
has to pay for the laboratory services provided on December 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment (99199, E1390) provided on June 22, 
2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the provider in this case is not a Medicare-enrolled provider and is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for oxygen equipment (99199, E1390) 
provided on June 22, 2022.