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

 
We decided that the Plan has to pay for a dental extraction (D7210) provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that the services denied correctly as you do not 
meet the clinical requirements to be approved. 
 
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. the Plan has not submitted medical records to indicate that the service did not 
meet clinical requirements. Therefore, we decided that the Plan has to pay for a dental extraction (D7210) 
provided on November 30, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alcohol wipes. 
 
You asked the Plan to pre-approve alcohol wipes. You say that you would like reconsideration because the 
requested alcohol wipes are medically necessary. The Plan denied your request. The Plan says the requested 
alcohol wipes are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the alcohol wipes.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovascular aortic aneurysm repair. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that imaging of the iliac arteries shows no evidence of aneurysm. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has an abdominal aortic aneurysm and that as greater than 5 cm in diameter. Treatment 
of this with an endovascular device is both reasonable and medically necessary. The decision to repair an 
abdominal aortic aneurysm involves more than simply aneurysm diameter. One needs to consider other patient 
factors including the anatomy and comorbidities. In this case, the enrollee's chronic obstructive pulmonary 
disease (COPD) potentially puts him at elevated risk for rupture than average for a particular aneurysm size. 
Additionally, the enrollee has satisfactory anatomy for endograft repair that may not be is satisfactory when the 
aneurysm enlarges. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve endovascular aortic aneurysm repair.  
 
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: 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. 
 
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 a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) 
retention. If that is present, the patient may benefit from bilevel positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
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 a Vagus nerve stimulator (64568). 
 
You asked the Plan to pre-approve a Vagus nerve stimulator. 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 follows Medicare rules. Medicare rules say that Vagus Nerve Stimulation (VNS) is a pulse generator, 
similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) 
is connected from the generator to the left vagus nerve. 
 
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 Vagus nerve stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the proposed use of VNS in 
this case is not consistent with the NCD. Therefore, this service would not be 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 Vagus nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vagus nerve stimulator (64568).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent Nursing Facility Care, per day (99308) 
provided January 20, 2023, to February 3, 2023. 
 
You asked the Plan to pay for the telehealth visit. You say that you have submitted the medical records and 
documents supporting he service. The Plan denied your request. The Plan says this service exceeds the 
frequency maximum allowed. 
 
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 99308 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded 
problem focused interval history; an expanded problem focused examination; medical decision making of low 
complexity. Usually, the patient is responding inadequately to therapy or has developed a minor complication. 
Typically, 15 minutes are spent at the bedside and on the patients facility floor or unit. 
 
We find that CPT code 99308 is not supported in the medical record. Specifically, the records show that the 
Plan previously paid for 99304 for date of service January 12, 2023, as well as another paid claim for date of 
service January 27, 2023. Therefore, the frequency allowed has been exceeded. Per CMS policy, CPT 99308 is 
limited to one service every 14 days and subsequent nursing facility care services are limited to one telehealth 
visit every 30 days. Based on this information, we decided that Medicare rules for coverage of the telehealth 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent Nursing 
Facility Care, per day (99308) provided January 20, 2023, to February 3, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cheilectomy with a vilex titanium implant. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation establishes that this enrollee is suffering with painful right hallux 
limitus/bunion deformity, unresponsive to numerous conservative treatments. X-rays reveal diminished joint 
space with osteoarthritic changes to the first metatarsal phalangeal joint (MPJ) on the right side. Hallux limitus 
with osteoarthritis can certainly be considered a poorly functioning portion of the foot and even a 
malformation. Diminished first MPJ space/hallux limitus responds very well to surgical treatments. Essentially, 
there are two procedures to address the diminished joint space/loss of cartilage to the first MPJ. The first is a 
hemi implant to the first MPJ, and the second is first MPJ arthrodesis. Both are extremely efficacious and 
certainly considered standard of care treatments for hallux limitus that has not responded to conservative 
treatments. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve cheilectomy with a vilex titanium implant.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service July 30, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT code 99284 is not supported in the medical record. Specifically, no medical records were 
submitted to the Plan for review. This means code 99284 is not supported by the documentation. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99284 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99284 for date of service July 30, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI of the lumbar spine. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the medical records do not show why the service is 
needed.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI of the lumbar spine. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found the enrollee has had 
bilateral foot pain and tingling for years. The enrollee's recent neurology exam showed normal reflexes. The 
electromyography performed on April 26, 2023, revealed large fiber neuropathy attributed either to their 
diabetes or childhood polio. There are no lumbar spine plain x-rays and no back pain. The enrollee has not had 
conservative therapy including 6 weeks of physical therapy. The medical necessity of the requested MRI 
lumbar spine has not been established in the submitted records. 
 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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on March 2, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that payment for the services at issue has been 
denied in error. The Plan denied your request. The Plan says Medicare does not cover acupuncture for any 
condition other than chronic low back pain. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the case record does not support that the acupuncture 
services at issue were rendered for treatment of chronic low back pain. Therefore, we decided that the Plan 
does not have to pay for acupuncture services provided on March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted procedure, nervous system provided on February 01, 
2023. 
 
You asked the Plan to pay for unlisted procedure, nervous system. You say that the services should be covered. 
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 unlisted procedure, 
nervous system provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each tocilizumab injection provided on 
January 18, 2023, to February 15, 2023. 
 
You asked the Plan to waive the coinsurance for each tocilizumab injection. You say that you cannot afford the 
coinsurance. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for each tocilizumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The amount you owe for each injection is $670.77 ($3,353.84 allowed amount x 
20% = $670.77). The total amount you owe is $1,341.54 ($670.77 coinsurance x 2 injections = $1,341.54). 
Therefore, we decided that the Plan does not have to waive the coinsurance for each tocilizumab injection 
provided on January 18, 2023, to February 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on November 07, 2022. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting the submitted documentation be 
reviewed. 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 ultrasound provided on 
November 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization services. 
 
You asked the Plan to pre-approve endovascular revascularization. You say that endovascular revascularization 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says endovascular 
revascularization is 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 endovascular revascularization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee's symptoms and ankle-brachial index (ABI) results are not 
consistent with lifestyle-limiting claudication or resting ischemia of the lower extremities. The enrollee's 
angiogram did not reveal any findings requiring treatment.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular revascularization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve endovascular revascularization services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 4, 2022, billed with 
codes 81162, 81201, 81249, 81727, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81218, 81236 and 
81325. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 4, 2022, billed with codes 81162, 81201, 81249, 81727, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81218, 81236 and 81325.