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

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth #22, #23, and #24. 
 
You asked the Plan to pre-approve D2750. You say that the enrollee can barely eat. The Plan denied your 
request. The Plan says a filling would suffice. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D2750 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 D2750. Our reviewer says that this 
dental work is not medically necessary. Our physician reviewer found crowns are not recommended on these 
teeth as the long-term prognosis is guarded to poor for these teeth due to the amount of bone loss around them. 
When the structures that support the teeth are compromised, the teeth may become loose.  
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 D2750 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve crowns (D2750) for teeth #22, #23, and #24.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885 and 99214 rendered on April 12, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) codes 95885 and 99214 remain 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 the denied codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 99214, there is 
no documentation to support a medically appropriate history/exam. The provided records in this case do not 
document an adequate social history and family history given the possibility of alcohol or other toxin-related 
neuropathy, and the possibility of hereditary neuropathy. The history also contains no details on the patient's 
level of renal dysfunction as uremic neuropathy is a recognized disorder or the enrollee's thyroid function (on 
levothyroxine) as hypothyroidism can cause neuropathy. Additionally, the records do not document that 30-39 
minutes of total time was spent on the encounter. 
 
Additionally, in terms of CPT 95885, the provided electromyography/nerve conduction study does not 
document all elements of CPT 95885 needle electromyography, each extremity, with related paraspinal areas 
with nerve conduction showing amplitude, latency and velocity.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95885 and 99214 rendered on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory panel testing provided on April 25, 2023. 
 
You asked the Plan to pay for lab panel. You say that the codes used are part of the panel which was 
performed. The Plan denied your request. The Plan says a single code that represents the panel should be 
reported. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease pathogen identification testing must be billed with a single code which is either the panels proprietary 
code or - in lieu of a proprietary code - procedure code 87999.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of lab panel have not been met. Therefore, we 
decided that the Plan does not have to pay for laboratory panel testing provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care in order to walk again 
and return to her family home where she was living independently prior to her illness. The Plan denied your 
request. The Plan says the enrollee has not been evaluated for any home health or skilled nursing needs. 
 
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 SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drug, Euflexxa. The records do not support that the required drug 
would be contraindicated or less effective; therefore, Synvisc-One is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The elements of the coverage criteria are not satisfied. The requested service 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
rendered on January 31, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service is not supported without the required documentation. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that at least 50 
minutes were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99233) rendered on January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vivaer procedure for nasal airway remodeling with 
radiofrequency. 
 
You asked the Plan to pre-approve the Vivaer procedure for nasal airway remodeling with radiofrequency. You 
say that the service is medically necessary. The Plan denied your request. The Plan says this service is 
considered experimental. 
 
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 Vivaer procedure for nasal airway 
remodeling with radiofrequency. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this particular procedure does not 
currently have sufficient high-quality evidence to support its effectiveness and safety over other treatments for this condition. 
 
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 Vivaer procedure for nasal airway remodeling with radiofrequency have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Vivaer procedure for nasal 
airway remodeling with radiofrequency.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Solid Tumor Profile Plus (81455) provided January 23, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that please see medical records to support the 
services rendered.  The Plan denied your request. The Plan says the records provided do not show that this 
request meets the Medicare medically necessary criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found with the documentation provided, it is not possible to determine whether the above criteria have 
been met. The physician notes documentation would need to be provided. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Solid Tumor Profile Plus (81455) provided January 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) performed 
on April 23, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found that the documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
performed on April 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-strength lightweight wheelchair (K0004) with 
accessories. 
 
You asked the Plan to pre-approve high-strength lightweight wheelchair. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the documentation does not show that the 
enrollee is unable to complete mobility-related activities of daily living with a standard or lightweight manual 
wheelchair, or that the width/depth/height cannot be accommodated in a standard, lightweight, or hemi-
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a high-strength lightweight manual wheelchair may 
be covered if certain 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 high-strength lightweight wheelchair. 
Our reviewer says that the enrollee does not meet criteria for this wheelchair. Our physician reviewer found the 
enrollee requires assistance with daily activities and can ambulate for short distances with a walker and stand-
by assistance. The enrollee is noted to have normal range of motion and can move all 4 extremities. The 
enrollee cannot functionally ambulate with a cane or walker and is at risk for falling. The enrollee requires a 
manual wheelchair for mobility in performing daily activities. However, the documentation is lacking in terms 
of why the enrollee cannot use or propel a standard wheelchair or standard lightweight wheelchair for mobility. 
The physical examination is limited in terms of the enrollees upper extremity graded motor strength. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high-strength lightweight wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a high-strength lightweight wheelchair (K0004) with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair repairs (K0739, E2392, E2374, 
K0108, E2376). 
 
You asked the Plan to pre-approve the power wheelchair repairs. You say that this should be covered. The Plan 
denied your request. The Plan says the cost of requested repairs appears to exceed the cost of replacement of 
the wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs are covered if they do not exceed the cost 
of replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power wheelchair repairs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair repairs (K0739, E2392, E2374, K0108, E2376).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix (Q4186) and 15 units of application of skin 
substitute graft (15271). 
 
You asked the Plan to pre-approve Epifix and 15 units of application of skin substitute graft. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 Epifix and 15 units of application of 
skin substitute graft. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this enrollee has peripheral arterial disease 
but not diabetic ulcers. Therefore, this is not reasonable nor 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 Epifix and 15 units of application of skin substitute graft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Epifix (Q4186) and 15 units of application of 
skin substitute graft (15271).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on June 11, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this was a basic life support emergency 
ambulance service with the correct Medicare diagnosis codes. The Plan denied your request. The Plan says 
these services were not medically necessary or reasonable.  
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
record indicates that the enrollee called the emergency medical services due to leg pain related to an accident in 
the distant past. The record indicates that the enrollee was ambulatory. The record does not indicate that an 
emergency situation, defined as one that a prudent layperson would believe that without immediate medical 
attention there would be serious jeopardy to the enrollee's health existed. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, emergency transport and ground mileage 
provided on June 11, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service May 3, 2022, to June 1, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should be reimbursed. The Plan denied 
your request. The Plan says that there is no qualifying skilled service. 
 
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 looked at the file and the rules. Medicare systems may return to the provider Low Utilization Payment 
Adjustment (LUPA) claims if the claim meets the criteria for a LUPA add-on payment, but it contains no 
qualifying skilled service. In this case, the claim was billed with qualifying services. Based on this information, 
we decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that 
the Plan has to pay for the home health care billed for dates of service May 3, 2022, to June 1, 2022.  
 
 
 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.