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

 
We decided that the Plan does not have to pre-approve a foot and multi-axial ankle system (L5981, L5986). 
 
You asked the Plan to pre-approve a foot and multi-axial ankle system. You say that the items are necessary. 
The Plan denied your request. The Plan says the advanced foot and ankle you received in August 2022 is still 
under warranty. Based on the documentation provided, coverage criteria have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a foot and multi-axial ankle system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a foot and multi-axial ankle system (L5981, L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the practitioner services provided on April 19, 2023, billed 
with procedure codes 96365-59, 96366-59, and 96521.  
 
You asked the Plan to pay for the practitioner services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the procedure codes 96365-59, 96366-59, and 96521 are not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug), additional hour. The definition of 
code 96521 is refilling and maintenance of portable pump.  
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services. Our reviewer says that the billing of 
these procedure codes is not supported. Our reviewer found that the medical record describes the Nova R 
intravenous treatment for an outpatient (96365, 96366). In this case, there are more descriptive procedure codes 
to support the services provided. The medical record also includes a physician order for the refilling and 
maintenance of a portable pump (96521); however, the procedure was not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services have not been met. Therefore, we decided that the Plan 
does not have to pay for the practitioner services provided on April 19, 2023, billed with procedure codes 
96365-59, 96366-59, and 96521.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography for congenital cardiac 
anomalies (93303) and transthoracic echocardiography with doppler (93306) to be provided at a tertiary level 
facility. 
 
You asked the Plan to pre-approve the transthoracic echocardiograms. You say that you need these tests to get 
a diagnosis of your conditions for treatment. You also say that your specialist only accepts tests from the 
requested providers on the referrals. The Plan denied your request. The Plan says there are community level 
facilities that can render the needed services. The Plan also says that your provider will accept the results of the 
procedure even if it is done at another hospital. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 transthoracic echocardiograms. Our reviewer says that the services are 
not medically necessary at a tertiary level of care. Our physician reviewer found that there are credentialed, 
experienced physicians within your network who could be utilized for the requested transthoracic 
echocardiograms (TTE). The records indicate that your condition should be adequately managed by the non-
tertiary level of care provided in-network. In summary, there is insufficient documentation to support the 
medical necessity for the referral to an out-of-network provider for the TTE or 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 the transthoracic echocardiograms have not been met.  
 
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 the transthoracic echocardiograms. Therefore, we 
decided that the Plan does not have to pre-approve a transthoracic echocardiography for congenital cardiac 
anomalies (93303) and transthoracic echocardiography with doppler (93306) to be provided at a tertiary level 
facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 5, 2022, at 
the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that J96.01 
is supported. The Plan denied your request. The Plan says the diagnosis code, J96.01, is not supported. 
 
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 principal diagnosis code, J96.01, defined as acute 
respiratory failure with hypoxia. 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 billed diagnosis code is not supported. 
Our physician reviewer found the patient had evidence of a pulmonary embolism, which did not significantly 
affect the enrollee's respiratory status to require high flow oxygen, bi-level positive airway pressure, or vent 
support. Therefore, the diagnosis, acute respiratory failure with hypoxia is not sufficiently supported in the 
documentation for this admission.   
 
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 on November 5, 2022, at the DRG originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says that facet joint 
injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 injections. Our reviewer says that 
the enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee's symptoms are 
consistent with facet arthropathy. Therefore, the enrollee meets the LCD criteria, and the request is medically 
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 the injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections.  
 
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 waive the copayment for inpatient hospital care provided on June 22, 
2022, to June 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $175 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $175 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay $875 ($175 x 5 days = $875). This item/service falls within the inpatient 
hospital care 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 waive the copayment for inpatient hospital care 
provided on June 22, 2022, to June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 3, 2023, by an OON 
provider.   
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 record shows you are not a network provider with the Plan. The Plan had network providers available who 
could have provided the items/services at issue in this appeal. 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 office visit provided on April 3, 2023, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on August 14, 2022. You asked the Plan to pay for the air ambulance transport services and air mileage. You say that based on 
clinical documentation and a registered nurse who has multiple years of critical care field experience, believes 
this transport meets medical necessity guidelines.  The Plan denied your request. The Plan says after 
reassessing the entire clinical situation, information provided at the time of the appeal does not support criteria 
for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport services and air 
mileage. Our reviewer says that the air ambulance transport services was not medically necessary. Our 
physician reviewer found while transfer for neurologic services was medically necessary and reasonable, the 
use of an air ambulance to complete the transfer was not. The enrollee was medically stable and there appear to 
have been multiple closer facilities. There is no evidence that the receiving facility was the only facility with 
capability and availability. 
 
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 air ambulance transport services and air mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, conventional air services, 
transport, one way and air mileage provided on August 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you are not at high risk 
for an unplanned hospitalization. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on March 
30, 2023, by an OON provider.  
 
You asked the Plan to pay for the chronic care management services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 chronic care management services provided on 
March 30, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery charger and back up battery. 
 
You asked the Plan to pre-approve a battery charger and back up battery.. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these are considered convenience items for a backup 
wheelchair.  
 
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 charger and back up battery.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve manipulation of TMJ under anesthesia. 
 
You asked the Plan to pre-approve manipulation of TMJ under anesthesia. You say that the request is 
medically necessary. The Plan denied your request. The Plan says that the request is denied because the records 
received do not show a dislocated joint needing to be put back in place. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers manipulation 
of temporomandibular joint under anesthesia when the services are medically necessary and reasonable. 
 
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 manipulation of temporomandibular 
joint under anesthesia. Our reviewer says that the request is medically necessary. Our physician reviewer found 
the documentation provided meets the criteria of medically reasonable and necessary for coverage of TMJ 
manipulation. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of manipulation of temporomandibular joint under anesthesia have been met. 
Therefore, we decided that the Plan has to pre-approve manipulation of TMJ under anesthesia.  
 
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 provide reimbursement for the podiatry office visit provided on 
April 3, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the office visit. You say that you went to this provider for 
better care. The Plan denied your request. The Plan says this service was not authorized. 
 
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 provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for these items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the podiatry 
office visit provided on April 3, 2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is appropriate and 
the only option for a safe discharge for the enrollee. The Plan denied your request. The Plan says an LTACH 
admission 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan.  
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 LTACH services.
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 you require additional SNF care because you are 
still unable to walk. The Plan denied your request. The Plan says the enrollee no longer requires skilled nursing 
as they have reached the maximum rehabilitation potential. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not qualify for SNF coverage. You do not have documented skilled 
nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition. Your care needs, custodial and intermittent, can be provided at a lower 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure provided on January 20, 2023, by 
an OON provider.  
 
You asked the Plan to pay for a debridement procedure. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 a debridement procedure provided on January 20, 
2023, by an OON provider.