Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that you need these injections to improve 
your condition. The Plan denied your request. The Plan says that the documentation does not show how your 
activities of daily living are affected by your back pain. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the 
criteria listed in the Medicare rules section 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 the facet joint injections. Our reviewer 
says that the requested injections are shown to be medically reasonable and necessary. Our physician reviewer 
found this enrollee has chronic low back pain. In 2014, she sustained a fall. At that time, she had anterior 
lumbar fusion surgery and radiofrequency ablation (RFA) of lumbar facets. Physical exam currently supports 
the diagnosis of facet dysfunction. Given the examination, the diagnostic injections are 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 the facet joint injections have been met. Therefore, we decided that the Plan has 
to pre-approve diagnostic facet joint injections.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stereotactic body radiation therapy (SBRT) (77014, 
77370, 77373, 77470). 
 
You asked the Plan to pre-approve the SBRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no need for the SBRT, and it would be considered non-standard and 
not generally accepted. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not demonstrate necessity and the treatment not being furnished in 
accordance with accepted standards 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 the SBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the stereotactic body radiation therapy (SBRT) (77014, 77370, 77373, 77470).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve porcelain/ceramic crown (D2740) for tooth #3. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee is experiencing pain and 
sensitivity with this tooth, and this crown is medically necessary. The Plan denied your request. The Plan says 
that the requested crown is not medically necessary in this case. 
 
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 the dental 
service 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 the dental service. Our physician 
reviewer found the requested crown on tooth #3 is not medically necessary. As standard restoratives cannot 
adequately, a crown would be the only reasonable restorative method reasonable in this circumstance. The 
requested treatment in recognition of the clinical situation would make the crown on #3 medically necessary. 
 
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 the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve porcelain/ceramic crown (D2740) for tooth #3.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on December 3, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that this should be paid. The Plan denied 
your request. The Plan says this was not billed according to the LCA rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the Florida Medicare contractor requires that two 
diagnosis codes be used for ambulance claims, including one from a list of 7 approved codes. 
 
We looked at the file and Medicare rules. The claim does not include one of the 7 required secondary diagnosis 
codes. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
provided on December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin; glysolated (A1C) (83036) and thyroid 
stimulating hormone (TSH) (84443) provided on October 11, 2022. 
 
You asked the Plan to pay for the A1C and TSH testing. The Plan denied your request. The Plan says screening 
tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the A1C and TSH testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the hemoglobin; glysolated (A1C) (83036) and thyroid stimulating hormone (TSH) (84443) 
provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on April 14, 2022, billed with code 99221. 
 
You asked the Plan to pay for the EM services as billed. You say that this code is supported. The Plan denied 
your request. The Plan says the code 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 99221 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the billed code is not supported in this case. Our reviewer found the provided records in this case do not 
document an extended examination of the affected body area and other symptomatic or related organ systems; 
the provided exam includes documentation of the vital signs and "Physical exam normal." Provided records in 
this case document at least 2 out of 3 of a minimal number of diagnoses or management options, a minimal 
amount and complexity of data reviewed and minimal risk of complication. All three required elements for 
support of code 99221 are not 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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital evaluation and management (EM) services provided on April 14, 
2022, billed with code 99221.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six Freestyle Libre 2 Sensors for 70 days. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensors. 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. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Freestyle Libre 2 Sensors. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found it is appropriate to 
not approve the continuous glucose monitoring (cgm) beyond the 14days per the plan guidelines that require 
the enrollee be on insulin or have symptomatic low blood glucose (bgs) in order to qualify for the cgm. If he is 
noted to be having low bgs in the future or if insulin is resumed then the cgm should be represcribed and 
approved but currently he does not meet criteria for coverage. 
 
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 Freestyle Libre 2 Sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six Freestyle Libre 2 Sensors for 70 days.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA) (22514). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for specified indications. 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that there is no trial of bracing. 
More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous Vertebral Augmentation (PVA) (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment  includes modification and 
placement (D6056 x4), adjust maxillofacial prosthetic appliance, by report (D6010 x4), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210 x1), bone replacement graft for ridge preservation - per site (D7953 x9), biologic materials to 
aid in soft and osseous tissue regeneration, per site (D4265 x9), overdenture  complete maxillary (D5863 x1), 
and overdenture  complete mandibular (D5865 x1). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the dental services represented by codes D6056, D6010 and D7210  has already been exhausted. 
The Plan also says that coverage is limited to those services set forth in the 2023 Schedule of Covered Benefit 
chart, therefore codes D7953, D4265, D5863, and D5865 are not listed, therefore they are not covered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the dental service codes represented by  D6010, D6056 and D7210 was exhausted on 
the initial review. The dental services represented by codes D7953, D4265, D5863, and D5865 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutment  includes modification and placement (D6056 x4), adjust maxillofacial prosthetic 
appliance, by report (D6010 x4), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated (D7210 x1), bone replacement graft for ridge 
preservation - per site (D7953 x9), biologic materials to aid in soft and osseous tissue regeneration, per site 
(D4265 x9), overdenture  complete maxillary (D5863 x1), and overdenture  complete mandibular (D5865 
x1).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the review has determined that the complexity of the enrollee's nursing, medical, 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve a routine transportation trip for a total of 55 miles. 
 
You asked the Plan to approve these services. You say that you need additional mileage to see your surgeon. 
The Plan denied your request. The Plan says the request exceeds the mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers routine transportation for 48 one-way trips and each one-way trip must not exceed 50 
miles. 
 
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
one-way trip for a total of 55 miles. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to approve a 
routine transportation trip for a total of 55 miles.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (ImpediMed L-Dex 
testing device) (93702). 
 
You asked the Plan to pre-approve an ImpediMed L-Dex testing device. You say that based on what you 
believe to be proven medical necessity, you would like this procedure to be authorized for the enrollee. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ImpediMed L-Dex testing device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a BIS assessment with the ImpediMed L-Dex device was requested for 
screening for lymphedema. However, current high quality, unbiased evidence is lacking for accurate results 
compared to other methods of screening for lymphedema to sufficiently support this request. Our reviewer 
found that the National Comprehensive Cancer Network (NCCN) guidelines still do not recommend the use of 
BIS but rather recommend a systems-based approach. Our physician reviewer found that therefore, this request 
for BIS assessment using ImpediMed L-Dex will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ImpediMed L-Dex testing device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (ImpediMed L-Dex testing 
device) (93702).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 Health Plans denial should be upheld. The enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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 pay for procedure code 99222 provided on September 22, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the medical records support the billing of 
code 99222. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99222. 
 
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 99222 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99222. Our reviewer says that the medical 
records do not support the billing of code 99222. Specifically, there was no comprehensive history or 
comprehensive examination. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 provided on September 22, 2022.