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

 We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on January 25, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 is not supported in the medical record. Specifically, 
there is a more appropriate code to describe Outpatient Intravenous Insulin Treatment (G9147). Code 96366 is 
an add-on code billed without an appropriate primary code. The procedure report provided does not document 
pump maintenance or refill, so code  96521 is not supported. There is a more appropriate code than J1817 to 
describe the insulin administration provided. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 96365, 96366, 96521, and J1817 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided on January 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you do not think you can do physical therapy 
comfortably. The Plan denied your request. The Plan says a sacroiliac joint injection 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 injection. Our reviewer says that 
you do not meet the coverage criteria. Our physician reviewer found that you have sacroiliitis. Also there is no 
documentation of conservative therapy within the past year. The LCD criteria requires 6 weeks of conservative 
therapy before any injection therapy. Therefore, the request is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visits provided from January 26, 2023, to 
January 31, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that you do not recognize the claims 
from the provider. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records confirming services were rendered. 
Therefore, we decided that the Plan has to waive the copayment for the office visits provided from January 26, 
2023, to January 31, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 ventilation system (E0466). 
 
You asked the Plan to pre-approve a Life2000 ventilation system. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 ventilation system. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Life2000 system 
is not medically necessary. The Life2000 system is not a true ventilator because it is not capable of providing 
full ventilatory support. It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
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 Life2000 ventilation system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Life2000 ventilation system (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure. 
 
You asked the Plan to pre-approve a posterior interspinous decompression spacer procedure. You say that a 
posterior interspinous decompression spacer procedure is medically necessary. The Plan denied your request. 
The Plan says a posterior interspinous decompression spacer procedure is unproven and 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 a posterior interspinous decompression 
spacer procedure. Our reviewer says that the requested posterior interspinous decompression spacer procedure 
is not considered medically reasonable and necessary in this case. Our physician reviewer found that posterior interspinous spacers are experimental. More research is needed. 
 
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 posterior interspinous decompression spacer procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression 
spacer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic surgeon office visit to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a thoracic surgeon office visit. You say that the enrollee wants to continue 
seeing the provider seen previously. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a thoracic surgeon office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
admission to an IRF.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, a comprehensive oral 
evaluation, and intraoral x-rays (D0150, D0210, D4341) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the periodontal scaling and root planing denied correctly as these 
services do not fall under your dental 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 17, 2021 
(D0150, D0210). Periodontal scaling and root planing services are not among those covered by this benefit. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing, a 
comprehensive oral evaluation, and intraoral x-rays (D0150, D0210, D4341) provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic services provided on November 22, 2021, to November 23, 
2021.  
 
You asked the Plan to pay for the chiropractic services . You say that you were never notified there was a 
timeframe for reimbursement requests.  The Plan denied your request. The Plan says that services were filed 
after the time limit. The Plan says that all claims must be received by one year after the service was performed.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case file includes a call log where a health plan representative notes that the 
enrollee submitted a claim for reimbursement on August 2, 2022, which was denied due to an ICD-10 
diagnosis code issue. There is no clear evidence of when the enrollees first claim submission was received, or 
that it was untimely. The Plan has not substantiated their denial reason or provided the necessary 
documentation for review. Therefore, we decided that the Plan has to pay for chiropractic services provided on 
November 22, 2021, to November 23, 2021.   
 
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 pre-approve special radiation called electronic brachytherapy (EB) 
(0394T, 77280, 77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that brachytherapy is the best option for 
the enrollee because brachytherapy delivers a higher dose of radiation directly to the tumor while sparing 
healthy tissue nearby. The Plan denied your request. The Plan says the plan benefits say that unproven 
treatments cannot be covered except in special circumstances. EB is considered unproven for the enrollee's 
condition. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of basal cell carcinoma of the right inferior helix and the 
left forearm.  Provided medical records and review of the current peer-reviewed medical literature do not 
document that use of electronic brachytherapy has been shown in controlled studies in a CMS-approved journal 
to result in long term health benefits in enrollees with basal cell carcinoma. As summarized in the guidelines of 
the National Comprehensive Cancer Network (NCCN): " There are insufficient long-term efficacy and safety 
data to support the routine use of electronic surface brachytherapy for treatment of basal cell skin cancer". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve special radiation called electronic brachytherapy (EB) (0394T, 77280, 77290).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425, A0170) provided on 
December 26, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says this claim was submitted with 
incompatible diagnosis codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, this claim was submitted with diagnosis codes 
R52 (pain, unspecified) and M79.606 (pain in leg, unspecified). However, diagnosis code R52 has an 
Excludes1 not for limb pain (codes within the M79.6 code set). This means that these two codes cannot be 
reported together. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428, 
A0425, A0170) provided on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that this is medically necessary. The 
Plan denied your request. The Plan says your tooth must have noticeable bone loss or show on an x-ray that 
there is a hard substance built up on the root of the tooth. Your x-rays do not show that you have these issues. 
 
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 Plan covers deep gum and 
root cleaning when the services are medically necessary and reasonable.  
 
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 deep gum and root cleaning. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found a review of the documentation did not indicate four or more teeth in each quadrant with periodontal pockets greater than 4mm 
or bone loss. There was no narrative indicating the nature of procedure D4999. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of deep gum and root cleaning have not been met. Therefore, we decided that the 
Plan does not have to pre-approve deep gum and root cleaning (D4341).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator (64581). 
 
You asked the Plan to pre-approve a sacral nerve stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says records show enrollee does not have documentation of a voiding diary.  
The Plan follows Medicare rules. Medicare rules say that a sacral nerve stimulator can be covered when 
specific criteria are met. 
 
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 sacral nerve stimulator. Our reviewer 
says that coverage criteria are not met for the requested service. Our physician reviewer found the provided 
records in this case do not clarify that the enrollee's improvement with a test stimulation is objectively 
documented through a voiding diary as required. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator (64581).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee will require noninvasive mechanical 
ventilation at home to manage COPD and chronic respiratory failure.  The Plan denied your request. The Plan 
says under Medicare guidelines, this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent 
to COPD. The home ventilator is being requested for use in intelligent volume assured pressure support 
intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by 
a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and 
a back-up rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. The provided records in this case do not provide adequate detailed information to meet Medicare 
criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
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 you are requesting an appeal for the denial of a 
continued SNF stay. You say you are receiving physical and occupational therapy and have improved, but you 
are not ready to leave yet. The Plan denied your request. The Plan says you no longer meet the rules for 
coverage of SNF care. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, the provided records do 
not document a significant decline in your functional status, compared to your recent baseline, to necessitate 
daily inpatient skilled therapy services. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. The records support that services in the home with 
home health care or in a long-term care facility on a part-time basis are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.