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

 
We decided that the Plan does not have to pay for the car wheelchair lift (E1399) provided on May 12, 2023. 
 
You asked the Plan to pay for the car wheelchair lift. You say that the item should be covered. The Plan denied 
your request. The Plan says a wheelchair lift does not primarily serve a medical purpose and cannot be used in 
the home. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose and be used in the home.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature or used within the 
home. Therefore, we decided that the Plan does not have to pay for the car wheelchair lift (E1399) provided on 
May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27197 and 27220 rendered on May 25, 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 the denied codes remain 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 the denied codes is: 
 
CPT 27197: 
 
Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, 
sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic 
symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation  
CPT 27220: 
 
Closed treatment of acetabulum (hip socket) fracture(s); without manipulation 
 
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 enrollee was being treated for 
a nondisplaced fracture of the anterior column (iliopubic) of the left acetabulum. The enrollee presented on 
5/25/22 with left-sided hip pain when they are mobilizing. The exam reveals she is able to actively straight leg 
raise. Motor and sensation are intact. However, detailed documentation is not consistently evident that 
treatments to the areas as specifically delineated in the CPT codes were provided. 
 
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 procedure code 27197 and 27220 rendered on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #29, #30, and #31 and the 
core buildup (D2950) for tooth #29 and to pay for a limited oral evaluation (D0140), the intraoral radiographic 
image (D0220), the core buildup (D2950) for tooth #30 and #31, the root canal (D3330) for tooth #18, the 
surgical placement of implant body (D6010) for tooth #18, a pontic (D6241) for tooth #4, a retainer crown 
(D6791) for tooth #3, an extraction (D7210) for tooth #4, and the surgery (D7921) provided by an out-of-
network provider on February 5, 2021, March 18, 2021, March 24, 2021, August 4, 2022, and October 3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that because of your surgery you would like 
the Plan to cover the dental services. The Plan denied your request. The Plan says your maximum dental 
benefit for the year of 2021 has already been exhausted. The dental services received on August 4, 2022, were 
from an out-of-network provider and are not covered by your supplemental benefits. The pontic and retainer 
crown are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The requested dental services in dispute meets the Medicare definition of dental, since it is a service which 
involved the care and treatment of teeth or structures directly supporting the teeth. The dental services do not 
fall under any of Medicare exceptions for coverage of non-routine dental care. Though the Plan offers a dental 
benefit in excess of Medicare coverage, certain limitations apply. The record shows the Plan paid $1,500 for 
dental services on February 5, 2021; therefore, your annual maximum benefit for the year of 2021 was 
exhausted on the date of service of February 5, 2021. The record shows you received the surgical placement of 
implant body, extraction, and surgery from an out-of-network provider. Though the Plan offers a dental benefit 
in excess of Medicare coverage, the requested items or services are not covered under this benefit when 
received from an out-of-network provider. The pontic and retainer crown are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pay more for a crown (D2740) for tooth #29, 
#30, and #31 and the core buildup (D2950) for tooth #29 and to pay for a limited oral evaluation (D0140), the 
intraoral radiographic image (D0220), the core buildup (D2950) for tooth #30 and #31, the root canal (D3330) 
for tooth #18, the surgical placement of implant body (D6010) for tooth #18, a pontic (D6241) for tooth #4, a 
retainer crown (D6791) for tooth #3, an extraction (D7210) for tooth #4, and the surgery (D7921) provided by 
an out-of-network provider on February 5, 2021, March 18, 2021, March 24, 2021, August 4, 2022, and 
October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on November 21, 2022, and 
December 22, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the enrollee did not know there was no 
prescription in place. The Plan denied your request. The Plan says an in-person visit is required every six 
months. The Plan also says that prior authorization is required for charges exceeding $1,000. 
 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 record shows the diabetic supplies were not authorized. The 
documentation indicates that the enrollee did not 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 diabetic supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the diabetic supplies provided on November 21, 2022, and December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service April 
21, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
The CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism. We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these codes 
represent not otherwise specified codes. A complete description of the not otherwise specified code was not 
included. The order/lab requisition/claim must include what laboratory test was ordered/requested to validate 
the codes billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 
83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 83520 and 87798 for date of service April 21, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program.  
There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown 
(D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown . You say that the 
services were approved while the dentist was in-network and there was no indication from the plan on the 
changes so the plan should pay. The Plan denied your request. The Plan says this service is not a covered 
expense under your dental plan. 
 
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, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated post and core in addition to crown (D2954).
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 you need extensive care, treatment and therapy. You 
say this decision should be overturned immediately so you can start receiving the care that you need. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical 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.  
 
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: 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 you are requesting reconsideration for the denial of 
inpatient rehabilitation. The Plan denied your request. The Plan says criteria for admission to the acute 
inpatient rehabilitation setting have not been met.  
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. 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.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on October 26, 2022, to October 
31, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
principal diagnosis A41.9 and secondary diagnosis R65.20 are supported in the documentation, therefore the 
claim should be paid at the DRG originally billed. The Plan denied your request. The Plan says that A41.9 and 
R65.20 are not supported in the documentation. 
 
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 A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis R65.20, defined as severe sepsis without septic shock. 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 principal diagnosis A41.9 and secondary diagnosis R65.20 are 
supported in the documentation. Our physician reviewer found the enrollee had documented leukocytosis, 
tachycardia, tachypnea, and elevated creatinine with urinary tract infection, meeting criteria for severe sepsis. 
Therefore, diagnosis codes A41.9 and R65.20 are justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on October 26, 2022, to October 31, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 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 procedure code 99222 billed for date of service January 19, 
2023. 
 You asked the Plan to pay for the billed services. You say that the highlighted note shows the date of service. 
The Plan denied your request. The Plan says the validity and accuracy of the claim cannot be verified. 
 
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 CPT code 99222 is not supported in the medical record. The medical records do not accurately 
identify an evaluation and management visit for the date of service at issue. The highlighted portion of the 
medical records, as noted in the appeal, identifies a pelvic x-ray provided and when the note was signed. 
However, the records do not show when this evaluation was actually provided. 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 procedure code 99222 billed for date of service January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve the PAE. You say that the enrollee is in need of this service. You also say 
that the medical records provided support the medical necessity. The Plan denied your request. The Plan says 
this is experimental for the enrollee's condition and therefore is not covered. 
 
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 PAE. Our reviewer says that the 
requested PAE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
prostate artery embolization (PAE) is not medically reasonable and necessary in this case. Prostatic arterial 
embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia 
(BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting due to the heterogeneity in the 
available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular 
access, technical feasibility, higher clinical failure rate compared with more traditional methods. Therefore, the 
reviewer found that the requested PAE 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 PAE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve prostate artery embolization (PAE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided on June 
17, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you have paid for this 
equipment for a long time and should no longer have a 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 20% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the oxygen concentrator. This item/service falls within the in-
network durable medical equipment 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. The total you owe is $32.90 ($164.48 allowed amount x 20% 
coinsurance = $32.90). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
oxygen concentrator provided on June 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your 
request. The Plan says studies have not proven that this drug is helpful for treatment of the enrollee's condition. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet criteria for use of Eylea. Our physician reviewer found Eylea is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Eylea.