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

 
We decided that the Plan does not have to pay for procedure codes 96374, D9222, and D9223 billed for date of 
service October 27, 2022. 
 
You asked the Plan to pay for procedure codes 96374, D9222, and D9223. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 
96374 is bundled into payment for code 30580. Additionally, dental codes D9222 and D9223 are not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that Medicare generally does 
not cover dental services. The Plan follows the same rule. 
 
In this case, we have confirmed that code 96374 is a column II code to column I code 30580. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met.  
 
Additionally, dental codes D9222 and D9223 are not covered by Medicare or the Plan. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 96374, D9222, and D9223 billed 
for date of service October 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits 
  
You asked the Plan to pre-approve the therapy services. You say that you still have back problems and can 
barely walk. The Plan denied your request. The Plan says the records do not support the need for additional 
visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you have progressed well with 13 visits and have 
reached a level of function with continued progress expected. An additional 12 visits beyond the 25 visits 
approved is not medically necessary based on your response to therapy and capacity for a home exercise 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 physical therapy visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture - (D5225), and mandibular partial denture - flexible base (D5226).

You asked the Plan to pre-approve the maxillary partial and mandibular partial dentures. You say that you lost your tooth where the partial denture is attached, and you cannot use the bridge. You also say that you need the approval of the partial to be done. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plan's 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 requested item or service was exhausted on date of service October 26, 2020. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5225), and mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement; however, the documentation does not support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the member would 
require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the 
supervision of a physician with at least three (3) visits weekly to regain or maintain his functional status. You 
can receive further services 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the provided documentation does not 
clearly show that the enrollee is currently being treated with insulin or requires frequent daily adjustments in 
treatment. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate 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 procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you are requesting reconsideration for the 
denial of a partial lower denture. The Plan denied your request. The Plan says this service is not covered under 
your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2 sensor. You say that the CGM will give the patient 
the glucose data needed to make dietary and lifestyle changes to improve blood sugar and health in general. 
The Plan denied your request. The Plan says the Medicare guidance says a continuous glucose monitor is 
covered under Medicare only if a member with diabetes is on insulin or has documentation of history of 
problematic low blood sugars. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met. Based on 
this information, we decided that Medicare rules for coverage of the FreeStyle Libre Kit 2 sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystourethroscopy with insertion of permanent 
adjustable transprostatic implant (52441, 52442). 
 
 
You asked the Plan to pre-approve the Urolift procedure. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this requested procedure 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 the Urolift procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the peer-reviewed literature regarding prostatic urethral lift (PUL) (i.e., UroLift) has been medically proven to be effective and, therefore, is considered medically appropriate for patients with 
symptomatic benign prostatic hyperplasia (BPH) who meet all of the following criteria and may desire 
preservation of erectile and ejaculatory function, A) persistent or progressive, moderate-to-severe lower urinary 
tract symptoms despite medical therapy (e.g., alpha blocker, phosphodiesterase type 5 (PDE5) Inhibitor, 
finasteride/dutasteride) for at least three months or inability to tolerate medical therapy for BPH, B) estimated 
prostate volume less than 80 cubic centimeter (cc)., C) no obstructive median lobe of the prostate identified on 
cystoscopy; and D) no signs or symptoms of urinary tract infection (UTI). There is no documentation that the 
enrollee was ever put on medical therapy (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride) for at 
least three months or inability to tolerate medical therapy. The records shown that the member has a moderate 
median lobe. The Urolift procedure is not medically reasonable and necessary in this case. 
 
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 Urolift procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cystourethroscopy with insertion of permanent adjustable transprostatic implant 
(52441, 52442).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for durable medical equipment provided on 
February 27, 2023. 
 
You asked the Plan to waive the deductible for durable medical equipment. You say that you are disputing the 
share cost. 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 $611.74 
deductible for Durable Medical Equipment (DME) and related supplies.  
 
You have been asked to pay $611.74 deductible for durable medical equipment. This item/service falls within 
the Durable Medical Equipment (DME) and related supplies 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 deductible for durable medical equipment provided on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive metabolic panel provided 
on January 6, 2023. 
 
You asked the Plan to waive the copayment for comprehensive metabolic panel. You say that you are disputing 
the share cost. 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 $40 
copayment for Laboratory services.  
 
You have been asked to pay $19.09 which is less than the $40 copayment for comprehensive metabolic panel. 
This item/service falls within the Laboratory 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 waive the 
copayment for comprehensive metabolic panel provided on January 6, 2023.
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 the enrollee is not ready to be discharged from SNF 
and requires 24-hour supervision. The Plan denied your request. The Plan says the member does not meet the 
Medicare SNF requirements. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. the enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95822 billed for date of service December 1, 2021. 
 
You asked the Plan to pay for code 95822. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 95822-26-XU is not supported by the medical record. 
 
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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
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 code 95822. Our reviewer says that code 95822 is not 
supported by the medical record. Our reviewer found the medical record describes Electroencephalogram 
(EEG) during non-intracranial surgery was performed during ACDF C4-C7, PCDF procedure.  In this case, 
there is a more appropriate code to report for service provided. Code 95822 is not documented in the procedure 
report, and therefore cannot be verified.  Electroencephalogram or EEG is a diagnostic test that uses small 
electrodes attached to the scalp to measure the electrical activity of the brain. In this procedure the provider 
performs the EEG when the patient is in a state of coma or sleep, this procedure is not documented in the 
procedure report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95822 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95822 billed for date of service December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria and the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 27, 2022, through 
July 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this hospitalization qualifies for inpatient payment under the two-midnight rule. The enrollee 
presented with chest pain. The enrollee was noted to have tachycardia and found to have bilateral pulmonary 
embolisms (PEs). At the time of admission, it was reasonable to believed that two midnights of care would be 
required to further evaluate and treat the enrollee. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 27, 2022, through July 30, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #3 (D7953). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation. The Plan denied your 
request. The Plan says this code is not listed in the table of covered services. 
 
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 pre-approve a 
bone replacement graft for ridge preservation - per site tooth #3 (D7953).