Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided on 
December 30, 2022. 
 
You asked the Plan to pay for the eye exam and refraction. You say that the receptionist scheduled you to have 
a yearly eye exam with a new provider on December 30, 2022. You also say that the appointment should have 
been scheduled after January 4, 2023. The Plan denied your request. The Plan says this claim processed and 
denied correctly per the Evidence of Coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to one supplemental routine eye exam every year. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a comprehensive eye exam n 
January 24, 2022, and your routine eye exam benefit had been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the eye exam and refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015) provided on 
December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that your current CGM is broken and sending incorrect 
readings. The Plan denied your request. The Plan says the clinical records did not indicate that the enrollee's 
current CGM was defective or broken. 
 
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 pre-approve the CGM. Our reviewer says that the 
criteria for switching the CGM are not met. Our physician reviewer found that the provided criteria states that a 
CGM may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident 
or to a natural disaster. CGMs can be off when compared with a fingerstick reading; this is due to the fact that 
the CGM measures interstitial fluid glucose and a meter measures blood glucose; the former can lag 15 minutes 
behind the latter. This can be the case with both Libre and a Dexcom. In addition, this enrollee is being 
prescribed Omnipod 5 which only works with Dexcom so it would be potentially dangerous to use Libre 
instead of the Dexcom. 
 
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 pre-approve a replacement continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your therapy requirements cannot be adequately 
addressed in a lower level of care. The Plan denied your request. The Plan says the request 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 your 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoluminal radiofrequency ablation (RFA) (36475). 
 
You asked the Plan to pre-approve endoluminal RFA. You say that these services are medically necessary and 
reasonable. The Plan denied your request. The Plan says this procedure is not medically necessary as there is 
no documentation that the enrollee's symptoms affect their activities of daily living. 
 
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 endoluminal RFA. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for the requested 
RFA in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoluminal RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endoluminal radiofrequency ablation (RFA) (36475).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (Prothrombin) and F5 (Factor V) testing (81241, 
81240). 
 
You asked the Plan to pre-approve F2 (Prothrombin) and F5 (Factor V) testing. You say that these tests are 
medically necessary and will impact your treatment. The Plan denied your request. The Plan says these services 
are not medically necessary, as there is not enough evidence to show that the results of these tests will 
effectively change treatment. 
 
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 F2 (Prothrombin) and F5 (Factor V) 
testing. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have a possible hypercoagulable state and have remained on coumadin for years. You have no history of venous thromboembolism prior to the age of 45 or a 
family history. It is unclear how testing for hypercoagulable would change your management, as medical notes 
state you would likely need to remain on anticoagulation. The requested tests are not reasonable or 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 F2 (Prothrombin) and F5 (Factor V) testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve F2 (Prothrombin) and F5 (Factor V) testing (81241, 81240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests, pair (for use with capped rental 
wheelchair base) (K0195). 
 
You asked the Plan to pre-approve elevating leg rests. You say that please review the attached appeal request 
for a denied authorization. The Plan denied your request. The Plan says this request in not supported based on 
the records received.  
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 elevating leg rests. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found accessories including elevating leg rests can be medically necessary if the member 
has significant edema or the lower extremities, if the wheelchair has a reclining back or if the member has a 
musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee. In 
this case, the documentation doesn't support that the enrollee has a medical condition that requires elevating leg 
rests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating leg rests have not been met. Therefore, we decided that the Plan does 
not have to pre-approve elevating leg rests, pair (for use with capped rental wheelchair base) (K0195).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has back pain and needs 
this procedure. The Plan denied your request. The Plan says this procedure is considered 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service December 2, 
2022.  
 
You asked the Plan to pay for procedure code 64488. You say that this code was billed for two units correctly 
as the injection was provided for the tranversus abdominis plane (TAP) and the rectal sheath. These are two 
distinct procedures.  The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64488 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. The code definition states that the 
block is for the TAP, consisting of the abdominal plane block and the rectus sheath block. As such, one unit 
refers to both injections.  
 
Based on this information, we decided that Medicare rules for coverage of procedure code 64488 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 64488 billed for date of 
service December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulator (NMES) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve NMES. You say that your device is differentiated from standard NMES 
devices. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the 
needed equipment can be provided within the 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 
a neuromuscular electrical stimulator (NMES) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50715-59-LT billed for date of service 
October 4, 2022. 
 
You asked the Plan to pay for procedure code 50715-59-LT. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service is not supported in 
the medical record and would be considered inclusive to code 22558. 
 
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 procedure code 50715-59-LT. Our reviewer says that this 
code is not supported as a separately identifiable procedure. Our reviewer found the record states that the 
ureterolysis at issue was performed as part of the approach for the anterior lumbar dicsectomy and fusion. According to CPT and NCCI rules, lysis of adhesions that are an integral part of the surgical approach included 
in the main procedure and not separately reportable. 
 
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 50715-59-LT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 50715-59-LT billed for date of service October 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis sacroiliac joint procedure. 
 
You asked the Plan to pre-approve an arthrodesis sacroiliac joint procedure. You say that the medical criteria 
have been met for this surgery. The Plan denied your request. The Plan says services are 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 an arthrodesis sacroiliac joint 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding imaging 
or radiographic evidence supporting a sacroiliitis pathology.  Therefore, the requested minimally invasive 
sacroiliac joint fusion, in this case, 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 an arthrodesis sacroiliac joint procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an arthrodesis sacroiliac joint procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on January 27, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 physical therapy services provided on January 27, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 10, 2022, to 
March 12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code J15.6, described as 
Pneumonia due to other Gram-negative bacteria, and secondary diagnosis code J96.01, described as Acute 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
codes. Our physician reviewer found that the enrollee presented with shortness of breath and was treated for 
pneumonia and Chronic obstructive pulmonary disease. There is no evidence that a gram-negative organism 
was identified as the cause of the enrollees pneumonia. Therefore, the billing of J15.6 is not supported. There 
is no evidence that the enrollee had respiratory failure. As such, the billing of J96.01 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 10, 2022, to March 12, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker. 
 
You asked the Plan to pre-approve a rollator walker. You say that you would like this item to be able to 
mobilize within the home. The Plan denied your request. The Plan says the requested item is comparable to the 
item you have. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker. Your current walker serves the same purpose as a rollator walker. 
Therefore, we decided that the Plan does not have to pre-approve a rollator walker.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 13, 2022, billed with 
code 99285.  
 
You asked the Plan to pay for the services as billed. You say that multiple exams were performed on this date, 
so the service is not duplicate. The Plan denied your request. The Plan says the claim was correctly denied as 
duplicate to a paid claim.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services as billed have been met. 
The file shows that payment was made to the rendering provider's billing group for both codes 99285 and 
93010. The provider did not include evidence to show that more than one visit was provided on this date to 
support payment of a second unit of 99285. Therefore, we decided that the Plan does not have to pay for the 
services provided on November 13, 2022, billed with code 99285.
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 the CGM. You say that the enrollee needs to monitor their blood glucose 
levels to control their diabetes. The Plan denied your request. The Plan says the Medicare 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 pre-approve the CGM. Our reviewer says that the 
criteria for the CGM coverage are not met. Our physician reviewer found that the provided criteria require 
insulin use or low blood glucose sugar levels that are symptomatic in order to cover a CGM. This enrollee is 
not on medications that typically cause low blood glucose sugar levels. The enrollee is not using insulin. There 
are no symptomatic low blood glucose sugar levels noted. 
 
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 pre-approve a continuous glucose monitor (CGM).