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

 
We decided that the Plan does not have to pay for the ophthalmic diagnostic imaging and the outpatient office 
visit provided on March 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ophthalmic diagnostic imaging and the outpatient office visit. You say that 
you need to be reimbursed for these services due to your economical and emotional situation. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 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 the ophthalmic diagnostic imaging and the 
outpatient office visit provided on March 28, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for June 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 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 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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the submitted records document that an appropriate history and physical examination were performed; however, they do not support a high complexity level of medical decision 
making. Code 99285 is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for June 8, 2023.
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 compliance issues with BIPAP prior and 
did tolerate bilevel positive airway pressure (BIPAP) when hospitalized per documentation. The enrollee would 
benefit from initiation of BIPAP and has not attempted nor had sufficient treatment with BIPAP to constitute a 
failure. Hence, with documentation proved, does not meet requirements for home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (36247). 
 
You asked the Plan to pre-approve the service. You say that the requested service is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested service is a medical necessity for the 
enrollee. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found prostate artery embolization (36247) is not medically reasonable and necessary in this 
case. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent American Urological Association (AUA) guidelines do not recommend this 
procedure outside of a clinical trial setting due to the heterogeneity in the available literature and safety 
concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, 
higher clinical failure rate compared with more traditional methods (for example, transurethral resection of the 
prostate [TURP]). 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (36247).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy infusion, aprepitant injection, 
prochlorperazine injection, famotidine injection, lorazepam injection, hydrocortisone sodium succinate 
injection, diphenhydramine injection, and normal saline solution infusion (J0185, S0028, J9060, J2060, J0780, 
J1720, J1200, J7050, 96413, 96415, 96417, 96368) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve chemotherapy infusion, aprepitant injection, prochlorperazine injection, 
famotidine injection, lorazepam injection, hydrocortisone sodium succinate injection, diphenhydramine 
injection, and normal saline solution infusion to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chemotherapy infusion, aprepitant injection, prochlorperazine injection, famotidine injection, lorazepam 
injection, hydrocortisone sodium succinate injection, diphenhydramine injection, and normal saline solution 
infusion (J0185, S0028, J9060, J2060, J0780, J1720, J1200, J7050, 96413, 96415, 96417, 96368) to be 
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from July 6, 2023, to July 
7, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you were unable to bring your medication 
into the hospital and would like the self-administered medication to be covered by the Plan. 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 pay for self-administered drugs provided 
from July 6, 2023, to July 7, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's care can be 
provided safely and effectively at a lower level of care such as a skilled nursing facility once the enrollee is 
medically stable and has completed their full course of care in the current hospital. 
 
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 appears to still be somewhat unstable and requires short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Completion of treatment at the current facility is 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that previously a BiPAP was tried by the enrollee, 
but it did not sufficiently resolve their condition. You say that a BiPAP is unsuitable because it would fail to 
improve or stabilize the enrollee's condition and the enrollee would benefit from extra support while 
mobilizing. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this enrollee because their needs can be met with an alternative device such as a BiPAP device with average 
volume-assured pressure support (AVAPS). 
 
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 the ventilator. Our physician reviewer 
found the enrollee has severe COPD and is on BiPAP with compensated acid base status. If further therapy 
were needed would recommend considering BiPAP with AVAPS. There is no worsening of acidosis and 
appears relatively compensated with prior arterial blood gas (ABG). Therefore, the enrollee does not currently 
meet criteria for home ventilator per the documentation 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
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 IRF admission is necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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 
does not support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain their functional status. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from MARCH 20, 2023, through MARCH 31, 2023. 
 
You asked the Plan to pay for the IRF care. You say that the IRF stay was medically necessary. The Plan 
denied your request. The Plan says the enrollee did not meet the criteria for the IRF stay. 
 
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 pay for the 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 enrollees nursing, medical and rehabilitation needs did not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee did not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee had a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does nott 
support that the enrollee would have met criteria for admission to an acute inpatient rehabilitation facility. 
There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain their functional status. 
 
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 pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from MARCH 20, 
2023, through MARCH 31, 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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says IRF care 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement; however, the documentation does not support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain your functional status. You 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radio frequency ablation (RFA) 
(64454). 
 
You asked the Plan to pre-approve genicular nerve RFA. 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 genicular nerve 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 literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. 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. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radio frequency ablation (RFA) (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of 
bone (D7210) for six teeth, gingival irrigation (D4921) for four quadrants, and the placement of five intra-
socket biological dressing to aid in hemostasis or clot stabilization (D7922). 
 
You asked the Plan to pre-approve the dental services. You say that the Plan approved your dentures, but did 
not approve your 12 extractions. You also say that you do not have teeth in the front and cannot eat well. The 
Plan denied your request. The Plan says your benefit for the surgical removal of erupted tooth requiring 
removal of bone (D7210) has already been exhausted. Gingival irrigation (D4921) for four quadrants, and the 
placement of five intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) are 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the surgical removal of erupted tooth requiring removal of bone (D7210) was exhausted 
on date of service with this requested date of service. The record also shows that Gingival irrigation (D4921) 
for four quadrants, and the placement of five intra-socket biological dressing to aid in hemostasis or clot 
stabilization (D7922) are excluded from this benefit. Therefore, we decided that the Plan does not have to pre-
approve surgical removal of erupted tooth requiring removal of bone (D7210) for six teeth, gingival irrigation 
(D4921) for four quadrants, and the placement of five intra-socket biological dressing to aid in hemostasis or 
clot stabilization (D7922).