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

 
We decided that the Plan does not have to pre-approve ferric carboxymaltose injection. 
 
You asked the Plan to pre-approve ferric carboxymaltose injection. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ferric carboxymaltose is only covered for certain 
indications. 
 
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 ferric carboxymaltose injection. 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 of a reported diagnosis iron deficiency anemia.  The 
record provided does not document that the enrollee has anemia or iron deficiency. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. 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 ferric carboxymaltose injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ferric carboxymaltose injection.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental crowns-porcelain fused to high noble metal for teeth 
number 24 and 25 (D2750 x 2).  
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested dental items are not medically 
necessary.  
 
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 these dental 
items when 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 these dental items. Our reviewer says 
that the requested dental items are medically necessary. Our physician reviewer found that the documentation 
provided indicates that teeth number 24 and 25 appear to have significant coronal breakdown that warrants 
crown restorations to provide adequate masticatory function and support.  
 
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 these dental items have been met. Therefore, we decided that the Plan has to 
pre-approve dental crowns-porcelain fused to high noble metal for teeth number 24 and 25 (D2750 x 2).   
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service October 26, 
2022, to November 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 26, 2022. The NOA was not received by the Plan until November 
27, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service October 26, 2022, to November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs this device. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and the record does not show 
that the enrollee has failed use of a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87636) billed for date of service 
December 12, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-agent 
testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent testing 
(87636) billed for date of service December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear stress test provided by an out-
of-network provider on February 22, 2023. 
 
You asked the Plan to waive the cost sharing for the nuclear stress test. You say that you were informed that 
the provider was in-network. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for all out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 You have been asked to pay a $476.68 coinsurance for the nuclear stress test because the Plan is only holding 
you responsible for this amount which is less than the 40% coinsurance. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost sharing for the nuclear stress test provided by an out-of-network provider on February 22, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buccal / labial frenectomy (frenulectomy) (D7961), 
lingual frenectomy (frenulectomy) (D7962), alveoloplasty in conjunction with extractions - four or more teeth 
or tooth spaces, per quadrant (D7310), and removal of torus palatinus (D7472). 
 
You asked the Plan to pre-approve the dental services represented by codes D7961 D7962, D7310 and D7472. 
You say that you have 16 teeth that need to be extracted for dentures. You also say that you have had a tooth 
infection for 6 months where you received prescriptions and pre-dental work for a future knee replacement. 
The Plan denied your request. The Plan says these services are not covered by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
buccal / labial frenectomy (frenulectomy) (D7961), lingual frenectomy (frenulectomy) (D7962), alveoloplasty 
in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310), and removal of torus 
palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  first 15 minutes 
(D9222), and each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you have 16 teeth that 
need to be extracted for dentures. You also say that you have had a tooth infection for 6 months and you 
received prescriptions and pre-dental work for a future knee replacement. The Plan denied your request. The 
Plan says deep sedation/general anesthesia is not a covered benefit. 
 
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 deep 
sedation/general anesthesia  first 15 minutes (D9222), and each subsequent 15 minute increment (D9223).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the surgeon advised you need to try Botox injections 
prior to surgery. The Plan denied your request. The Plan says Botox to treat gastroparesis 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 Botox. Our reviewer says that the 
coverage criteria is not satisfied, and the requested service cannot be recommended. Our physician reviewer 
found that you have a diagnosis of gastroparesis. The requested drug is not indicated for your condition and is 
not supported by Medicare approved drug compendia in your clinical situation.  
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 14, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
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 a $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 14301 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 14301. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says the payment for this procedure is included in the payment for 
procedure 27447 which was provided on May 9, 2022, and has a 90-day global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a postoperative period of 90 days applies to major surgeries. The payment for the surgical 
procedure includes payment for all related care provided during the postoperative period. Modifiers 79 and 24 
are used to report services performed by the same physician which are unrelated to the initial procedure and 
therefore require separate payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 14301 have not been met. Specifically, this service was performed by the same 
physician within the 90-day global surgery period of another procedure. This service was not billed with a 
necessary modifier to indicate that it is not related to and therefore not included in the payment for the previous 
procedure. Therefore, we decided that the Plan does not have to pay for procedure code 14301 billed for date of 
service June 1, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87798-59, 87481-59 and 87801-59 billed for date of 
service December 6, 2022. 
 
You asked the Plan to pay for procedure codes 87798-59, 87481-59 and 87801-59. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says that these 
services are denied. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for procedure codes 87798-59, 87481-59 and 
87801-59 billed for date of service December 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 06, 2023. 
 
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 that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the admission to a LTACH is not medically necessary. 
 
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 that there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 LTACH services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
February 06, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. You say that you disagree with 
the 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 a $300 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $300 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an outpatient diagnostic tests provided on February 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service December 
21, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this code is not supported for the 
services provided. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says that this code is 
not supported for the level of service provided. Our reviewer found although the documentation supports a 
comprehensive history and comprehensive examination, it does not support medical decision making of 
moderate complexity and does not reflect 50 minutes spent at the enrollee's bedside. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 billed for date of service December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 09, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 allowed amount for the DME is $5,995. You are being asked to 
pay $568.26 ($5,995 x 20% = $1,199). However, you are only being asked to pay $568.26 which is less than 
the required amount. Therefore, we decided that the Plan does not have to waive the coinsurance for durable 
medical equipment (DME) provided on February 09, 2023.