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

 
We decided that the Plan does not have to pay for procedure code 99100-GY billed for date of service March 
23, 2023. 
 
You asked the Plan to pay for procedure code 99100-GY. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code 99100-GY is considered bundled and not 
separately payable.  
 
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 procedure code 99100-GY has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99100-GY is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99100-GY have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99100-GY billed for date of service March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for het pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an astigmatism correcting function of intraocular 
lens provided on January 17, 2023, and March 7, 2023. 
 
You asked the Plan to reimburse you for the astigmatism correcting function of intraocular lens. The Plan 
denied your request. The Plan says although astigmatism correcting IOLs may serve the same function as 
eyeglasses or contact lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact 
lenses. Therefore, the astigmatism-correcting functionality of an IOL does not fall into the vision benefit 
category and is not covered.  
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism 
correcting feature of an IOL. Therefore, we decided that the Plan does not have to reimburse you for an 
astigmatism correcting function of intraocular lens provided on January 17, 2023, and March 7, 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 the enrollee's condition has stabilized, 
and they require a multi-disciplinary approach for an extended period. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee does not require any LTACH services that they are not currently 
receiving at the health care setting being provided by the Plan. The services are not medically necessary and 
cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve radiation therapy. You say that this is the closest facility able to provide the 
needed treatment. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and the enrollee 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 
radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of the Optimizer Smart permanent cardiac 
contractility modulation system (0408T, C1824). 
 
You asked the Plan to pre-approve the insertion of the Optimizer Smart permanent cardiac contractility 
modulation system. You say that this is medically necessary. The Plan denied your request. The Plan says this 
service is considered experimental and investigational. 
 
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 insertion of the Optimizer Smart 
permanent cardiac contractility modulation system. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility 
modulation remains the subject of multiple studies examining long-term efficacy, as well as randomized, 
controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are 
completed, it is premature to presume clinical outcomes and benefit. 
 
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 insertion of the Optimizer Smart permanent cardiac contractility modulation 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of the 
Optimizer Smart permanent cardiac contractility modulation system (0408T, C1824).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D7922 (x2)). 
 
You asked the Plan to pre-approve the dental service (D7922 (x2)). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the dental service (D7922) 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 the 
dental service (D7922 (x2)).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97530 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that 2 units of CPT code 97530 is not supported in the medical record. The code reported should be 
selected based on the time closest to that indicated in the code descriptor. The exact time spent for code 97530 
was not documented. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97530 
billed for date of service May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, 83789, G0480) provided on June 12, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 80307, 83789, & G0480 are not supported in the medical record. Specifically, the 
original lab requisition notes orders for a custom panel, but it does not specify which specific tests are to be 
performed. Code 83789 is included in the lab services and is not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (80307, 83789, G0480) provided on June 12, 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 an IRF admission would be beneficial for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees nursing, medical, and rehabilitation needs are complex. However, they 
do 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 medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided at a lower 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve vacuum socket system. 
 
You asked the Plan to pre-approve vacuum socket system. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 vacuum socket system. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has experienced a significant change in the volume of the enrollee's 
residual limb with atrophy and the enrollee's current prosthetic socket no longer fits the residual limb despite 
attempted modification. The enrollee requires a new prosthetic socket for the enrollee's prosthesis, which is 
necessary for mobility and performing daily activities. The enrollee has attempted different suspension systems 
and the vacuum assisted socket suspension system allows for the best fit and accommodation for the volume 
fluctuation of his residual limb throughout the day. There is medical literature indicating that this type of 
suspension system can be helpful in enrollees with volume fluctuation. Therefore, the vacuum assisted socket 
suspension system is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vacuum socket system have been met. Therefore, we decided that the Plan has 
to pre-approve vacuum socket system.  
 
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 skilled nursing (G0299). 
 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 is 
noted to have a wound of the right heal, but it is not high risk for infection and the complexity of wound care 
does not require skilled nursing care at this point. The enrollee does not require catheterization, tube feeding, or 
administration of intravenous medications. The enrollee is modified independent with mobility and may require 
some degree of assistance and supervision, but this does not require skilled nursing care. The enrollee has had 
no recent 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 skilled nursing (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the cervical RFA. You say that you need this surgery. You say that you are 
in too much pain. You also say that you need this done as soon as possible. The Plan denied your request. The 
Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions (both diagnostic and 
therapeutic) are limited to one spinal region per session. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cervical RFA have not been met. Therefore, we decided that the Plan does not have to pre-
approve a cervical radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical access to implant body (D6011) for tooth 
#3, #4. and #5. 
  
You asked the Plan to pre-approve the dental services. You say that you have not used up all your dental 
benefits so the dental procedures should be approved. The Plan denied your request. The Plan says the denial of 
authorization for the surgical access to implant body is correct, because it cannot be applied until 3 months 
after the surgical placement of implant body. 
 
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. The Plan covers the dental 
services 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 the dental services. Our reviewer says 
that the surgical access to implant body does not meet the Plan's coverage criteria. Our physician reviewer 
found that the submission of first and second stage surgery for implants appears to be an administrative issue, 
as a second stage uncovering of the implant body would be necessary but not for 3 months following the initial 
placement. The second stage procedure would be necessary at the proper time. 
 
The submission of first stage and second stage surgery for implants for pre-determination appears to be an 
administrative issue, as there is no specific date presented for the procedures (they have not been completed) 
and the fact the 2 procedures need to be separated in time cannot be presented as such in a pre-determination on 
an American dental association (ADA) form. There must be an administrative review of the pre-determination 
to allow for benefits assessment without regard to the time frame of the procedures, acknowledging that the 
second stage procedure would be performed 3 months following initial placement. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the surgical access to implant body (D6011) for tooth #3, #4. and #5.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imbruvica. 
 
You asked the Plan to pre-approve Imbruvica. 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 Imbruvica.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 60 routine transportation trips. 
 
You asked the Plan to pre-approve the additional 60 routine transportation trips. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you currently have 2 trips remaining and you 
will have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 60 routine transportation trips.
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 is having difficulty performing activities 
of daily living and was previously independent and worked out weekly. You say the enrollee is motivated to 
participate in three hours of therapy daily and meets IRF criteria. The Plan denied your request. The Plan says 
the enrollee's needs can be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do 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, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services at a lower 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.