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

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99233 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99233 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says that 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are medically necessary Our physician reviewer found the enrollee has documented failure of bilevel 
positive airway pressure (BIPAP) and BIPAP with average volume assured pressure support (AVAPS) therapy, 
in additional to having supporting arterial blood gas (ABG). The enrollee does meet criteria for home ventilator 
for continued support of her chronic respiratory failure. Hence, the enrollee meets criteria and best practice 
standards for a home ventilator. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a ventilator (E0466).  
 
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 methotrexate. 
 
You asked the Plan to pre-approve methotrexate. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0861) and 
additional items and accessories (codes E2377, E2313, E1028, E1008, E0955, E1012, E2311, E2361, and 
E2607). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you would like the medical documentation and quote which supports the need of the custom 
medical equipment being requested to be reviewed. The Plan denied your request. The Plan says this request is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has residual from Guillain Barre syndrome. The enrollee is able to 
manage self-care independently with a power wheelchair. Our reviewer also found that the enrollee does not 
have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means 
of managing power drive. 
 
 
 
 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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair (K0861) and additional items and accessories (codes E2377, E2313, E1028, E1008, E0955, E1012, 
E2311, E2361, and E2607).  
 
Please note: Our determination was not based on the replacement rules which the Plan used because this 
request was for an item that was not identical, and there was no evidence of the Plan having paid for and 
providing a Group 2 power wheelchair previously.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the skilled nursing facility (SNF) care on 
October 1, 2022, to October 14, 2022.  
 
You asked the Plan to waive the copayment for  the skilled nursing facility (SNF) care. You say that you want 
to appeal the amount being charged. 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 $0 
copayment per day for days 1-20 and a $188 copayment per day for days 21-100 for skilled nursing facility 
(SNF) care. There was a total of 24 days. There is a $188 copayment per day for days 21-100. This includes the 
SNF days 21-24. For the service it's 4 x $188 = $752. Therefore, results in the total cost sharing amount of 
$752. 
 
You have been asked to pay a $188 copayment per day for the skilled nursing facility (SNF) care. This 
item/service falls within the skilled nursing facility (SNF) 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. Therefore, we decided that the Plan does not have 
to waive the copayment for  the skilled nursing facility (SNF) care on October 1, 2022, to October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic exercises to be provided by a 
chiropractor. 
 
You asked the Plan to pre-approve the therapeutic exercises. You say that one visit per month usual helps to 
keep you pain free and active, although you might need a couple of treatments per month. You say that the 
visits have helped you maintain an active lifestyle. The Plan denied your request. The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve the therapeutic exercises to be provided by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 7, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you were told that these would be 
covered. The Plan denied your request. The Plan says the requested compression stockings are not covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on September 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay more. 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 your benefit for the requested item or service was exhausted on date of service March 24, 2023, and 
June 22, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
September 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on July 12, 2023. 
 
You asked the Plan to waive the copayment for an MRI. You say that you thought that the service was fully 
covered. 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 $150 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $150 copayment for an MRI. 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 
copayment for an MRI provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided by an out-of-
network provider on August 11, 2023. 
 
You asked the Plan to pay for the CGM. You say that you would like the claim paid because E2103 is a 
covered service by Medicare. The Plan denied your request. The Plan says the Medicare coverage criteria was 
not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM. Our reviewer says that the CGM 
coverage criteria was not met. Our physician reviewer found that the record provided does not indicate that the 
enrollee is being treated with insulin or has problematic hypoglycemia as defined by the Medicare rules. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pay for a continuous glucose monitor (CGM) provided by an out-of-network provider on August 11, 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 physical therapy to address 
strength, transfers and gait utilizing assistive device with focus patterns balance and coordination for fall 
prevention's. You say that the enrollee is expected to make measurable functional gains at an IRF, reflective of 
the improvement they have already made at the acute hospital. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog flexpens. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog flexpens.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (96401) provided on August 31, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 96401 is "Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic". 
 
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 use of code 96401 is 
supported by the records provided. Our reviewer found that the medical records do support the use of 
procedure code 96401 to be billed as the administration code, as the drug administered was a non-hormonal 
anti-neoplastic in accordance with CMS guidelines and CPT guidelines. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (96401) provided on August 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy (G0152 x5) and home 
health skilled nursing (G0299 x8). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not require additional skilled nursing or rehabilitation services to effectively provide treatment, care, 
and/or services in order to improve the enrollees condition, perform a maintenance program to maintain the 
enrollees condition and/or prevent deterioration. The enrollee has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health occupational therapy (G0152 x5) and home health skilled nursing 
(G0299 x8).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas treatment provided on March 1, 2023. 
 
You asked the Plan to pay for the Sanexas treatment. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by a certified nurse practitioner (CNP) who is not licensed to provide physical therapy in the 
State of Ohio. Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded 
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified 
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are 
not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we 
decided that Medicare rules for coverage of the Sanexas treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for the Sanexas treatment provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical additional radiographic image 
(D0230) provided on May 8, 2023. 
 
You asked the Plan to pay for the intraoral - periapical additional radiographic image. You say that the provider 
was on the sheet provided by the plan. The Plan denied your request. The Plan says your benefit for the 
requested intraoral - periapical additional radiographic image 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 Plan's 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 intraoral - periapical additional radiographic image was exhausted on date 
of service May 8, 2023. You received the allowed frequency of one intraoral - periapical x-ray on the appealed 
claim. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical additional 
radiographic image (D0230) provided on May 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve chemotherapy. You say that you were referred to this provider for further 
treatment options. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and you can be treated within the Plan 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 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 
chemotherapy services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mesalamine tablets. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve mesalamine tablets.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.