Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Ozempic.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CBCT) capture and 
interpretation (D0365) and a bone replacement graft for ridge preservation (D7953) provided on May 25, 2023 
to June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have a $3000 yearly dental benefit and this 
grafting should be covered as it is necessary for the implant to be successful. The Plan denied your request. The 
Plan says the requested dental codes are noncovered. 
 
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 a cone 
beam computed tomography (CBCT) capture and interpretation (D0365) and a bone replacement graft for ridge 
preservation (D7953) provided on May 25, 2023 to June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the powered pressure-reducing air mattress (E0277), 
purchased on May 31, 2023. 
 
You asked the Plan to pay for the powered pressure-reducing air mattress . You say that you needed this item. 
The Plan denied your request. The Plan says this item was obtained through a provider that is not certified with 
medicare. 
 
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 the powered pressure-reducing air 
mattress (E0277), purchased on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient rehab stay 
provided on May 04, 2023, to May 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient rehab stay. You say that this is a 
big bill, you were sick and need help with this. 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 $390 
copayment for inpatient hospital care.  
You have been asked to pay a $390 copayment for an in-network acute inpatient rehab stay. 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. You have been asked to pay a total of $780 for the inpatient hospital stay ($390 
copayment x 2 days = $780). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network acute inpatient rehab stay 
provided on May 04, 2023, to May 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dayspring wearable compression device. 
 
You asked the Plan to pre-approve the Dayspring wearable compression device. You say that the device is 
medically necessary. The Plan denied your request. The Plan says this device is considered experimental. 
 
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 Dayspring wearable compression 
device. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this device is considered experimental. 
 
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 Dayspring wearable compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Dayspring wearable compression device.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve .  
You asked the Plan to pre-approve a computed tomography (CT). The Plan says that this service is only 
supported once per year for five years after surgery. The Plan says the enrollee had a CT scan in January 2023. 
 
We decided that the Plan has to pre-approve .  
 
Therefore, we decided that the Plan has to pre-approve .  
The enrollee qualifies for computed tomography (CT) of abdomen and pelvis surveillance January 26, 2024    
considering the surgical history, prior CT of January 27, 2023 and lack of clinical recurrence. 
 
 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 chiropractic manipulative treatment provided on June 12, 
2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatment provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230), comprehensive oral evaluation (D0150) and the panoramic radiographic image (D0330) provided on 
August 16, 2023. 
 
 You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the intraoral - periapical each additional radiographic image, 
comprehensive oral evaluation and the panoramic radiographic image 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. The record 
shows your benefit for the comprehensive oral evaluation and panoramic radiographic image was exhausted on 
date of service December 2, 2022. Your benefit for the intraoral - periapical each additional radiographic image 
was exhausted on August 16, 2023. Therefore, we decided that the Plan does not have to pay for intraoral - 
periapical each additional radiographic image (D0230), comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on August 16, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that you would like reconsideration based on the records 
submitted.  The Plan denied your request. The Plan says that the requested drug 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 Leqvio. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found that the enrollee has tried atorvastatin, 
rosuvastatin, and ezetimibe without getting to their low-density lipoprotein (LDL) goal; they discussed the 
option of a proprotein convertase subtilisin/kexin type 9 (PCSK9) with the enrollee and they are not agreeable 
to self-injections. Chart notes document the enrollee is currently taking rosuvastatin 40mg every other day with 
an LDL of 72 on October 13, 2023. The review has determined that the use of Leqvio is FDA-approved for the 
enrollees diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have been met. Therefore, we decided that the Plan has to pre-approve 
Leqvio.  
 
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 practitioner services provided on January 14, 2023, billed 
with procedure code 45399-51. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 45399-51 is unlisted procedure, colon. 
 
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 provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that unlisted codes should only be reported when there is not an appropriate code to report the service performed. Based on the documentation submitted, 
there is an existing code that best fits the procedure performed. An unlisted code should not be reported. 
 
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 provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 14, 2023, billed with procedure 
code 45399-51.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99284 billed on date of service June 23, 2023. 
 
You asked the Plan to pay for 99284. You say that 99284 should be paid as billed because it is supported in the 
documentation and was coded correctly. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 12032 
provided on June 14, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management 
services described by code 99284 billed on date of service June 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on May 1, 2023. 
 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 this visit does not meet criteria for a higher level of care for CPT 99284. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that there was medical decision making of a moderate 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) rendered on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated scooter (K0800). 
 
You asked the Plan to pre-approve the scooter. You say that you need this scooter because it is light weight, 
and you cannot lift the other scooters. You also say that you need this scooter because it will give you freedom. 
The Plan denied your request. The Plan says the Medicare criteria has not been met, as the request does not 
address the elements of the coverage criteria of the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our physician reviewer 
found the documentation available for review does not support that the member requires a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication they are unable to use 
an alternative assistive device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (radiofrequency 
ablation). 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. 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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found sacral lateral nerve branch blocks and/or ablations/neurotomies for the 
diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or 
pulsed radiofrequency, is considered investigational and therefore, 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (radiofrequency ablation).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says there is not enough quality evidence to 
show that CardioMEMS is helpful. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the items are medically 
necessary. The Plan denied your request. The Plan says  there is no evidence that a scooter is medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the documentation available for review does not support that the enrollee 
requires a power mobility device to accomplish mobility related self-care tasks in the home. There is no 
indication they are unable to use an alternative assistive device. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle, patient weight 
capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 01999. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for procedure codes 01999 and 99100 provided on June 21, 2023. You say that you 
would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered as 
billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 01999.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 01999.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99100 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 99100. 
 
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.