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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the request for 
admission to a SNF does not meet the requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no unrevealing or indeterminate Holter Monitor or other non-
invasive cardiac monitor. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on electrocardiogram monitoring. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee is not a candidate for first-line Raynaud's 
therapies due to their cardiac disease (calcium channel blockers PDE5-I). You say the requested drug would be 
the ideal treatment for the enrollee because it has no systemic side effects and is likely to improve the enrollee's 
daily function. The Plan denied your request. The Plan says that medical studies have not proven that the 
requested drug is helpful for the treatment of the enrollee's problem.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Botox. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found, based on the community standards of 
care, the documentation supports that Botox is medically reasonable and necessary for the enrollee. The 
documentation supports that Botox is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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 keppra. 
 
You asked the Plan to pre-approve the medication. You say that the drug 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 keppra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are appealing on the grounds that 
Medicare has reviewed and approved. The Plan denied your request. The Plan says there is not a medical need 
to control these power options through the joystick. 
 
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 upgraded electronics. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation supports that the enrollee has adequate upper 
extremity strength to manage standard power drives. Therefore, the reviewer found that the requested upgraded 
electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a hypoglossal nerve stimulator (64582). 
 You asked the Plan to pre-approve implantation of a hypoglossal nerve stimulator. You say that this is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria as the 
BMI is not less than 35. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulation can be covered when 
specific criteria are met. 
 
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 implantation of a hypoglossal nerve 
stimulator. Our reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer 
found the records in this case do not document the enrollee's body mass index (BMI) is less than 35. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a hypoglossal nerve stimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantation of a hypoglossal nerve stimulator (64582).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, seat elevator, legrests) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that you 
are not mobile around the house. You also say that your walker does not work well around the house. The Plan 
denied your request. The Plan says the requested power wheelchair is not medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation does not support 
that you require a power wheelchair to manage self-care in the home. Therefore, the reviewer found that the 
requested Group 3 power wheelchair with multiple power options 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, seat elevator, legrests) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  a crown-porcelain/ceramic (D2740) 
provided on June 27, 2023. 
 
You asked the Plan to waive the coinsurance for  a crown-porcelain/ceramic. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. A core buildup is 
not a covered service. 
 
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 50% 
coinsurance for a crown-porcelain/ceramic.  
 
You have been asked to pay 50% coinsurance for a crown-porcelain/ceramic. This item/service falls within the 
crown-porcelain/ceramic 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. Also, a core buildup is not a covered service. Therefore, we decided that the Plan does not 
have to waive the coinsurance for  a crown-porcelain/ceramic (D2740) and pay for a core buildup (D2950) 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
procedure code 99152-GC. 
 
You asked the Plan to pay for the practitioner services provided. 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 code. 
 
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 99152-GC is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the record does not contain key 
elements of the code description for 99152. As such, this code is not supported. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with procedure code 
99152-GC.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service and annual visit provided on August 
03, 2023. 
 
You asked the Plan to pay for the laboratory service and annual visit. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
and annual visit provided on August 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on July 3, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over-
the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on July 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic electrocardiogram (TTE) with doppler, 
complete (93306). 
 
You asked the Plan to pre-approve the TTE. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the notes do not show new or worsening signs or symptoms of heart 
disease. 
 
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 TTE. Our reviewer says that the 
requested TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found 
a routine echocardiogram is not a medical necessity in an individual with no new, or worsening angina, heart 
failure, cardiac murmurs, palpitation, or arrhythmia. Therefore, the reviewer found that the requested TTE 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 the TTE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transthoracic electrocardiogram (TTE) with doppler, complete (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator. 
 You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that an ultrasonic 
osteogenesis stimulator is medically necessary. The Plan denied your request. The Plan says an ultrasonic 
osteogenesis stimulator is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is covered when 
the criteria listed in the Medicare rules section of this decision are met. 
 
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 ultrasonic osteogenesis stimulator. 
Our reviewer says that the requested ultrasonic osteogenesis stimulator is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that nine months have not passed since the surgery. 
More time is needed to establish a nonunion diagnosis. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray provided on March 21, 2022. 
 
You asked the Plan to pay for the wrist x-ray. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wrist x-ray provided 
on March 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services coded as 99232 performed on 
February 3, 2023. 
 
You asked the Plan to pay for 99232. You say that 99232 should be paid as billed because it was coded 
accurately and is supported in the documentation. The Plan denied your request. The Plan says that 99232 is 
denied because the number of units billed exceeds the maximum allowed. 
 
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 case file does not include proof that any other claim was 
submitted for the enrollee on the same date of service as the claim at issue for code 99232. In this instance, the 
case file only contains documentation of 1 unit of 99232 being billed on February 3, 2023. Without proof that 
another claim for code 99232 was billed on this same date of service by the same provider, or a provider of the 
same specialty in the same billing group, we are unable to confirm if the Plan was correct in denying 99232. 
Therefore, we decided that the Plan has to pay for the evaluation and management services coded as 99232 
performed on February 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab testing on May 24, 2023.  
 
You asked the Plan to waive the deductible for the lab testing. You say that please review medical notes per 
request. 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. Your 
contract with the Plan says that there is a combined maximum out-of-pocket $10,300 deductible which applies 
to outpatient diagnostic tests and therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a combined maximum out-of-pocket $10,300 deductible which applies to 
outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation 
that had not been met at the time the lab testing was received on May 24, 2023. Therefore, we decided that the 
Plan does not have to waive the deductible for the lab testing on May 24, 2023.