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

 
We decided that the Plan does not have to pay for unclassified drugs (procedure code J3490) rendered on 
August 10, 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 Healthcare Common Procedure Coding System (HCPCS) code J3490-KD (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J3490 is "Unclassified drugs." 
 
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 J3490 is not supported. There is a more specific code for the substance administered. An unspecified code should not be used is a more specific 
code exists. 
 
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 unclassified drugs (procedure code J3490) rendered on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that your mental health is being affected 
because you are unable to walk more than 10-15 minutes before getting tired of the pain in your left knee. You 
say that you have had a problem with your left knee for three years. The Plan denied your request. The Plan 
says the genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental therapy. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided on May 23, 2023. 
 
You asked the Plan to pay for moderate sedation services. You say that the services were billed correctly. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 moderate sedation services. Our reviewer says that the 
services are not supported. Our reviewer found the documentation submitted was reviewed and does not meet 
criteria. CPT 99153 is considered a technical component, as the surgeon is performing the surgical procedure, 
and an independent trained observer is monitoring the patient. Therefore, this procedure would not be reported 
by surgeon, when performed on campus-outpatient hospital (POS 22). We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for moderate sedation services provided on May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this CGM is medically necessary. The Plan denied 
your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
January 17, 2023, to January 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee should not 
be held responsible for the this service. 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 $350 
copayment for inpatient hospital care.  
You have been asked to pay a $350 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $1,750 for the inpatient hospital stay ($350 
copayment x 5 days = $1,750). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on January 
17, 2023, to January 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from May 
27, 2022, to May 31, 2022. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the documentation does not 
support a physical therapy/occupational therapy (PT/OT) function score of 10-23 or a nursing function score of 
6-14 during the date of service in question. 
 
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 skilled nursing facility (SNF) services rendered from May 27, 2022, to May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery (procedure code 66984) rendered on August 9, 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 66984 is "Extracapsular cataract removal with insertion 
of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration 
or phacoemulsification); without endoscopic cyclophotocoagulation." 
 
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 documentation submitted does 
not support that 66984 was performed on the date of service in question. There is no procedure note showing a 
procedure was performed. 
 
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 eye surgery (procedure code 66984) rendered on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 You asked the Plan to pre-approve an orthosis. You say that you need the brace because you cannot walk and 
cannot have surgery because you will have a heart attack due to anesthesia. The Plan denied your request. The 
Plan says based on Medicare guidelines, the knee brace (knee orthosis) requested does not meet the 
requirements for approval. 
 
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 an orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not meet the criteria as the records show that the enrollee has chronic arthritis 
of the knee without instability, recent surgery or acute injury.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve D5213. You say that you need this denture. The Plan denied your request. 
The Plan says the enrollee's tooth is in poor condition. 
 
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 D5213 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 D5213. Our reviewer says that this 
denture is not medically necessary. Our physician reviewer found the tooth has severe bone loss around it 
(more than 50% of bone is missing), which makes the long-term prognosis of this tooth poor. The ligament 
which is holding the tooth also looks compromised. When there is not enough supporting structures (bone, gum 
tissues) around a tooth, the tooth may be/become loose. In order to retain a partial denture, remaining teeth 
need to be stable (have enough bone and gums around it).  A more definitive treatment is required for the 
enrollee.  
 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 D5213 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on April 11, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for wound care. You say that the service was medically necessary. The Plan denied 
your request. The Plan says that their original decision to deny payment was correct. 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 wound care provided on April 11, 2023, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the stress test provided on August 11, 
2023. 
 
You asked the Plan to reduce the copayment for the stress test. You say that your plan has a maximum charge 
of $35 for specialist services and the $40 charge should be reduced to $35. 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 $40 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $40 copayment for the stress test. This item/service falls within the outpatient 
diagnostic tests 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 reduce the copayment for the stress test provided on 
August 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires continued SNF services to 
overcome mobility issues and regain their independence. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on January 11, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that these services should be covered. The 
Plan denied your request. The Plan says the provider was not licensed at the time of service. 
 
The Plan must follow Medicare rules. Medicare rules say that a qualified physical therapist (PT) is a person 
who is licensed, if applicable, as a PT by the state in which he or she is practicing unless licensure does not 
apply, has graduated from an accredited PT education program and passed a national examination approved by 
the state in which PT services are provided. 
 
We looked at the file and Medicare rules. The record shows that the license for the physical therapist that 
provided the services at issue expired prior to the date of service and was not renewed. Based on this 
information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on January 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1852) performed on January 23, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no evidence of any medical need for this brace. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has arthritis in the knee. There was no recent surgery or injury,  and no instability on 
exam. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1852) performed on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6209 billed for date of service September 6, 2023. 
 
You asked the Plan to pay for code A6209. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says procedure code A6209 is excluded from the fee schedule.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that code A6209 has a status indicator of P on the Physician Fee Schedule. This means that procedure 
code A6209 is excluded from the fee schedule and therefore, not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of code A6209 have not been met. Therefore, we decided that the 
Plan does not have to pay for code A6209 billed for date of service September 6, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient subsequent evaluation and management (EM) service 
provided on August 28, 2023, via telehealth. 
 
You asked the Plan to pay for the telehealth inpatient EM visit. You say that no other EM services were billed 
on this date for the provider at issue. The Plan denied your request. The Plan says that Medicare only allows 
one subsequent telehealth visit every three days. The Plan has paid for one the day before, so this claim was 
correctly 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. We find that the file does not include sufficient documentation to support the 
Plan's denial rationale. Though it is indicated that code 99232 was paid the day before the date at issue, no 
evidence was presented. Furthermore, it is not confirmed that this EM service from the day before was also 
provided via telehealth. As such, we find that the denial of payment is not substantiated. Therefore, we decided 
that the Plan has to pay for the inpatient subsequent evaluation and management (EM) service provided on 
August 28, 2023, via telehealth.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the documentation does not support an accepted 
medical indication for the use of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Retacrit. Our reviewer says that the 
requested use of Retacrit is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's specific condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. Therefore, the reviewer found that the requested drug, Retacrit, 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.