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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided September 7, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38510 and 38900 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 38510 and 38900. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 38510 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Since code 38510 has been denied, we 
have confirmed that code 38900 is an add-on code and has not been billed with an appropriate primary 
procedure code. 
 
Based on this information, we decided that Medicare rules for coverage of procedure code 38510 and 38900 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 38510 and 
38900 billed for date of service November 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested 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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for shoulder pain. The enrollee's conservative 
treatment included physical therapy, cortisone injections, and medications. The detailed documentation is not 
evident regarding any rotator cuff pathology on the noted computed tomography (CT) arthrogram. 
Additionally, the noted exams do not corroborate significant rotator cuff pathology over other potential causes of deficits. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. No compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the enrollee does not have a 
diagnosis/condition that meets the criteria for the requested services 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network acute IRF admission and services. 
 
You asked the Plan to pre-approve out-of-network IRF care. You say that the enrollee's medical management 
and rehabilitation needs require an inpatient rehabilitation stay and close physician supervision. The Plan 
denied your request. The Plan says there is no evidence that the enrollee's clinical situation cannot be addressed 
by an in-network provider. 
 
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 
out-of-network acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
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 use of intraoperative radiation 
therapy (IORT) with electronic brachytherapy is not the standard of care for the enrollee's condition. The 
services are not reasonable or medically necessary at this time. 
 
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 electronic brachytherapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97166 billed for date of service December 3, 
2021. 
 You asked the Plan to pay for procedure code 97166. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 97166 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 97166 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97166 billed for date of service December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
December 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the treatment was 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
December 6, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say the enrollee is a good candidate for acute inpatient rehabilitation, considered stable, 
and ready to transfer to the IRF. The Plan denied your request. The Plan says the request for admission to an 
IRF is denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services monthly 
(90960) provided on September 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ESRD services. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services monthly 
(90960) provided on September 1, 2022, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator and supplies provided on September 26, 2022. 
 
You asked the Plan to pay for the stimulator and supplies. The Plan denied your request. The Plan says that the 
proof of delivery did not include an order number or details to corroborate the delivery ticket submitted, and 
the proof of delivery is not itemized to indicate the specific supplies. 
 
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 argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 26, 2022, with the 
same tracking number as the delivery ticket dated October 3, 2022. As such, the records support that the items 
at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical stimulator 
and supplies 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for durable medical equipment supplied on September 16, 2022. 
 
You asked the Plan to pay for the services. You say that medical records were submitted for review. The Plan 
denied your request. The Plan says that the records do not support the services billed. 
 
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. Medicare rules also say that durable medical equipment (DME) supplies must be provided with a 
proof of delivery. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider sent in a screenshot of tracking that shows an item was delivered. 
There is an invoice/packing slip showing that the various denied items were shipped to the enrollee. The 
tracking number of the invoice and the tracking number on the screenshot match. The provider has met their 
requirements for verifying these services. The plan has therefore not substantiated their denial. Therefore, we 
decided that the Plan has to pay for durable medical equipment supplied on September 16, 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 pay for the additional moderate sedation time provided on date of 
service October 16, 2021, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service October 16, 2021, billed 
with code 99153.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health physical therapist visits. 
 You asked the Plan to pre-approve home health services. You say that the services are not medically necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 the enrollee 
plateaued in terms of their upper and lower extremity strength. They may continue to require some degree of 
assistance with transfers and mobility, but this does not require the continued services of skilled physical 
therapist. Therefore, the 2 visits of additional home health physical therapy are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 home health physical therapist visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat and want to appeal 
the denial of dental implants. The Plan denied your request. The Plan says these services are not covered by 
Medicare or the 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. Additionally, these services are not covered under your medical 
benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs a higher 
quantity of medication due to the diagnosis. The Plan denied your request. The Plan says this can be performed 
at an observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found there is no specific clinical rationale for the requested inpatient hospital 
services. The record does not show that at the time of inpatient admission the admitting physician would 
reasonably expect that the enrollee's necessary hospital care would span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.