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

 
We decided that the Plan does not have to pay for the wound care supplies provided on September 26, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that payment was denied for the wound care 
supplies that were delivered to the enrollee for their wound care treatment. You say that these supplies should 
be covered. The Plan denied your request. The Plan says the supplies were ordered by the skilled nursing 
facility and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the codes are not included in 
the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography, transesophageal, real-time with image 
documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, 
interpretation and report rendered on June 27, 2022. 
 
You asked the Plan to pay for the services. You say that medical records were sent for review. The Plan denied 
your request. The Plan says Current Procedural Terminology (CPT) code 93312-26, XU (1 Unit) remains 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 93312 is "Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report." 
 
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 during the anesthesia (CPT 
00567) there is a notation about transesophageal echocardiography (TTE - CPT 93312) but only with the 
remark "no evidence of trauma." No further description of findings was made, thus it appears that the TEE was 
part of the anesthesia, and not a separate procedure. 
 
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 echocardiography, transesophageal, real-time with image documentation (2D) (with or without 
M-mode recording); including probe placement, image acquisition, interpretation and report rendered on June 
27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the care and services required by this 
enrollee exceeds the clinical capabilities of all lower levels of care, and all physicians involved concur that 
LTACH is the appropriate level of care. The Plan denied your request. The Plan says the enrollee does not meet 
the guidelines for care in an LTACH.  
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the medical supplies provided on February 1, 2023.
We also decided that the Plan does not have to waive the cost share for the drug injection and ultrasound
provided on February 1, 2023.

You asked the Plan to waive the cost share for the medical supplies, drug injection, and ultrasound. You say
that you disagree with how the claim was processed. The Plan says that this cost sharing was charged correctly.

We decided that the Plan has to waive the coinsurance for the medical supplies provided on February 1,
2023.

According to Medicare the medical supplies that were charged a coinsurance amount (C1725, C1753, C1769,
C1894, C1876) are considered packaged codes and are not separately payable. These codes are also excluded
from the physician's free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the
medical supplies provided on February 1, 2023.

We also decided that the Plan does not have to waive the cost share for the drug injection and ultrasound
provided on February 1, 2023.

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 20%
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $125
copayment for outpatient diagnostic tests, including ultrasounds.

You have been asked to pay $4.39, which is 20% coinsurance of the allowed amount for the drug injection
($21.96 allowed amount x 20% coinsurance = $4.39). This item/service falls within the Medicare Part B drugs
benefit category. You have also been asked to pay a $125 copayment for the ultrasound. This item/service falls
within the outpatient diagnostic tests and therapeutic services benefit category. 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 cost share for the drug injection and ultrasound.

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 office visit (99204) and the therapeutic activities (97530) 
provided on January 31, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99204) and the therapeutic activities (97530) provided on 
January 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on January 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 use of code 99285 is 
not supported by the records provided. Our reviewer found that the provided documentation does not clearly describe a medically appropriate examination or a high level of medical decision-making to justify this code. 
 
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 the services (99285) provided on January 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 for date of service August 24, 2022. 
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
 
 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, we have confirmed that code 
procedure code 88341 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88341 for date of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.  
 
You asked the Plan to pre-approve a sacroiliac (SI) joint injection. You say that a sacroiliac (SI) joint injection 
is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac (SI) joint injection 
does not meet the Medicare LCD coverage criteria.  The Plan follows Medicare rules. 
 
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 sacroiliac (SI) joint injection. Our 
reviewer says that the requested sacroiliac (SI) joint injection is not considered medically necessary in this 
case. Our physician reviewer found the enrollee has low back pain and the diagnosis of sacroiliitis. The 
enrollee had six weeks of physical therapy and over the counter medications. The progress notes show the 
enrollee only had a positive response to two provocative maneuvers to evaluate for SI joint pain, which were 
the Yeoman's and posterior pelvic pain tests. All other SI joint provocative tests including FABER, distraction, 
and compression tests were negative. The Medicare LCD requires three positive tests. Therefore, at this point, 
the request is deemed not 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 a sacroiliac (SI) joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
You asked the Plan to pre-approve Supartz FX. You say that the medication is medically necessary. The Plan
denied your request. The Plan says that step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Supartz FX. Our reviewer says that
Supartz FX is not medically reasonable and necessary. The record indicates that the enrollee has osteoarthritis
of the knee. The requested medication is a new start. The provided records do not indicate that the enrollee has
tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a
contraindication to or would have an adverse effect from the plan's preferred step one alternative. Our
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not
have to pre-approve Supartz FX for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service February 2, 2023. You asked the Plan to pay for the billed services. You say that the lab results show the work was performed. 
The Plan denied your request. The Plan says the codes should not be unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
We find that the panel testing was not billed with a single code as required. Furthermore, there are insufficient 
medical records to show that the testing was necessary above the standard of care. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the panel testing billed for date of service February 2, 2023.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for coronary artery bypass grafting and valve replacement. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medication, Dalfampridine. 
 
You asked the Plan to pre-approve the medication, Dalfampridine. 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 the medication, 
Dalfampridine.  
 
Benefits for the medication, Dalfampridine 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left genicular nerve radiofrequency ablation procedure 
(64640 x3 and 64624). 
 
You asked the Plan to pre-approve a left genicular nerve radiofrequency ablation procedure. You say that this 
service has been recommended in attempt to decrease symptoms for a longer period of time. The Plan denied 
your request. The Plan says medical studies have not proven this service/item is helpful for the treatment of the 
enrollee's health problem. 
 
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 a left genicular nerve radiofrequency 
ablation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this procedure is the subject of ongoing 
clinical trials to determine its role in the management of knee osteoarthritis.  Our reviewer found that therefore, 
this request is deemed not 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 a left genicular nerve radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a left genicular nerve radiofrequency ablation 
procedure (64640 x3 and 64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel testing provided on January 27, 2023. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that moderately strong evidence exists that molecular diagnostics demonstrate increased sensitivity in detecting urinary bacteria at the expense of poor specificity in controls. Additional data comparing patient 
symptoms and cure rates following antibiotic selection directed by molecular methods compared with culture 
are needed to elucidate their place in urinary tract infection (UTI) care. As such, the requested urine testing at 
issue in this case is not medically reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine panel testing provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
complete series of radiographic images (D0210), topical application of fluoride varnish (D1206), the resin-
based composite-one surface posterior (D2391), the resin-based composites-two surfaces, posterior  
(D2392 x 2), adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including 
premalignant and malignant lesions (D0431), and the scaling in moderate or severe gingival inflammation 
(D4346) provided on December 13, 2022 and December 15, 2022. 
 
You asked the Plan to pay more for these services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, an adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities 
including premalignant and malignant lesions and the scaling in moderate or severe gingival inflammation are 
not covered under the supplemental dental policy.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, an adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including 
premalignant and malignant lesions and scaling in moderate or severe gingival inflammation are not covered 
under the supplemental dental policy. Therefore, we decided that the Plan does not have to pay more for the 
comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), topical 
application of fluoride varnish (D1206), the resin-based composite-one surface posterior (D2391), the resin-
based composites-two surfaces, posterior (D2392 x 2), adjunctive pre-diagnostic test that aids in the detection 
of mucosal abnormalities including premalignant and malignant lesions (D0431), and the scaling in moderate 
or severe gingival inflammation (D4346) provided on December 13, 2022 and December 15, 2022.