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

 
We decided that the Plan does not have to pay for procedure code 96366 billed for date of service May 16, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the number of 
units 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 3 units of CPT code 96366 is not supported in the medical record. The medical records show that 
the infusion time was 2.5 hours. Code 96365 was billed and paid for the first hour. 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 96366 billed for date of service May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy provided from January 11, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for the infrared therapy. You say that this should be covered. The Plan denied your 
request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy provided from January 11, 2023, to February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery system (E1399) and delivery 
(A9901), provided on January 19, 2023. 
 
You asked the Plan to pay for the face down recovery system and delivery. You say that the items should be 
covered. The Plan denied your request. The Plan says this was purchased through a supplier that is not enrolled 
in 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 face down recovery system (E1399) 
and delivery (A9901), provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nail debridement. 
 
You asked the Plan to pre-approve nail debridement. You say that you need additional nail debridement 
sessions. The Plan denied your request. The Plan says services exceeding this limit will deny not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover no more than six 
debridement session per 12 months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nail debridement have not been met. Therefore, we decided that the Plan does not have to pre-
approve nail debridement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you were previously approved 
for an oxygen tank. The Plan denied your request. The Plan says  a portable oxygen concentrator is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is not medically necessary. Our physician reviewer found 
that there may be clinical evidence that leads you to conclude that despite a level of oxygen saturation greater 
than 80%, supplemental oxygen is still medically necessary and reasonable. However, the records do not 
explain why the already approved portable oxygen tanks will not meet your needs for portability and why a 
portable oxygen concentrator is 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 a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the enrollee is severe neutropenia. The Plan denied 
your request. The Plan says Fulphila 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 Fulphila. Our reviewer says that 
Fulphila is not medically necessary. Our physician reviewer found that the requested use of Fulphila is not 
FDA-approved. Fulphila is also not supported by one of the major drug compendia or by clinical research. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivestym. 
 
You asked the Plan to pre-approve Nivestym. You say that Nivestym is medically necessary in treating other 
drug-induced agranulocytosis, and malignant neoplasm of pelvic bones, sacrum and coccyx. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nivestym. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of febrile neutropenia. The record indicates the white blood cell 
count is 2800. The record provided does not indicate that the enrollee has the indicated diagnosis. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivestym have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nivestym.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation services. 
 
You asked the Plan to pre-approve the additional transportation services. You say that the services are 
medically necessary for you to get to your therapy appointments. The Plan denied your request. The Plan says 
you have exceeded your transportation limit for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plans maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 19, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on June 19, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), and guided tissue 
regeneration (D7956). 
 
You asked the Plan to pre-approve a bone replacement graft and guided tissue regeneration. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the requested services are not 
covered benefits. 
 
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 (D7953), and guided tissue regeneration (D7956).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face mask interface (A7031), and filter (A7039), 
purchased on February 8, 2023. 
 
You asked the Plan to pay for the face mask and filter. You say that the items should be covered. The Plan 
denied your request. The Plan says these items were purchased through a supplier that is not enrolled in 
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 face mask interface (A7031), and 
filter (A7039), purchased on February 8, 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 the enrollee requires intensive inpatient rehabilitation 
with daily physician management , 24-hour specialized rehab nursing, and intensive therapies to optimize 
mobility and strengthening while ensuring the restoration of functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says an IRF admission is 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 the primary caregiver for your husband and 
need acute inpatient rehabilitation to take care of him. The Plan denied your request. The Plan says you do not 
meet the medical necessity requirements for acute inpatient rehabilitation facility services.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it was recommended that the enrollee be discharged 
to an IRF. The Plan denied your request. The Plan says the IRF admission is 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 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. There is not a 
reasonable expectation that the 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the general health panel provided by an in-
network provider on April 27, 2023, and the office visit provided by an in-network provider on May 5, 2023.  
 
You asked the Plan to waive the deductible for the health panel, and the office visit. You say that you were not 
advised of the deductible responsibility. 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. Your 
contract with the Plan says that there is a $226 deductible which applies to the general health panel, and the 
office visit. 
 
You have been asked to pay a $36.35 deductible for the health panel. This item or service you asked the Plan to 
waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. You have also been asked to pay a $119.93 deductible for the office visit. This item or service you 
asked the Plan to waive the deductible for falls within the physician/practitioner services, including doctor's 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $226 deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies, and physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the health panel, and the office visit were provided on April 27, 2023, and May 5, 2023. Therefore, we decided 
that the Plan does not have to waive the deductible for the general health panel provided by an in-network 
provider on April 27, 2023, and the office visit provided by an in-network provider on May 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves (A4927). 
 
You asked the Plan to pre-approve non-sterile gloves. You say that you need the requested large size gloves. 
The Plan denied your request. The Plan says non-reusable disposable supplies for home use, such as gloves are 
not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While non-sterile gloves may be appropriate in this case, neither the Plan nor Medicare offers coverage of these 
items. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scanning services provided on May 20, 2023. 
 
You asked the Plan to pay for 93306, 93880, 93931, 93979. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these codes 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 93306 is echocardiography, transthoracic, real-time with 
image documentation (2-dimensional), including M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography. The CPT Code Manual definition 
of code 93880 is duplex scan of extracranial arteries; complete bilateral study. The CPT Code Manual 
definition of code 93931 is duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or 
limited study. The CPT Code Manual definition of code 93979 is duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study. 
 
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 93306, 93880, 93931, 93979. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found these procedure codes are not supported in the 
documentation submitted. There is a more specific code to report instead of 93880. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93306, 93880, 93931, 93979 have not been met. Therefore, we decided that the 
Plan does not have to pay for duplex scanning services provided on May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on June 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should have been reimbursed more 
for the dental services you received. 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 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 you had not used all of your $2,000 allowance at the time of your appointment. The Plan shows you had 
only used $1,961.99 of your $2,000 allowance ($2,000 - $1,961.99 = $38.01). Therefore, the Plan reimbursed 
you the correct amount of $38.01, which exhausted your $2,000 annual allowance. Once you meet your annual 
allowance, you have an 80% coinsurance for out-of-network services. Therefore, we decided that the Plan does 
not have to pay more for the dental services provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee walker and a bed wedge pillow, purchased on June 6, 
2023. 
 
You asked the Plan to pay for a knee walker and a bed wedge pillow. You say that the items should be covered. 
The Plan denied your request. The Plan says these items were purchased through a provider that is not enrolled 
in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a knee 
walker and a bed wedge pillow, purchased on June 6, 2023.