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

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service May 20, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 physician 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 99285. Our reviewer says that the documentation does not support the code billed. Our reviewer found the enrollee presented with nausea and 
vomiting. Labs relatively normal. The enrollee was discharged with oral Zofran. The documentation supports 
comprehensive history and physical exam. However, documentation does not support high level of medical 
decision making. Therefore, code 99285 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service May 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the item is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 requested item or service was exhausted on date of service January 28, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve K0861, E0955, E1007, E1012, E1028, E2361, E2601, E2611. We 
decided that the Plan does not have to pre-approve E2311, E2313, E2377.  
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2601, and E2611). You say 
that the enrollee requires the K0861 base and all recommended components to meet their mobility, medical, 
and functional needs in their home. The Plan says that there is no medical need for the multiple power options. 
 
We decided that the Plan has to pre-approve K0861, E0955, E1007, E1012, E1028, E2361, E2601, E2611.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if 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 the power wheelchair and most of the accessories. Our 
reviewer says that the enrollee is at a high risk for skin breakdown per the Braden scale. The enrollee has 
chronic demyelinating polyneuropathy, advanced, progressive neurological disease, and requires maximal 
assistance for mobility. The enrollee also has bladder and bowel incontinence. The tilt and recline include the 
power leg rests and 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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve K0861, E0955, E1007, E1012, E1028, E2361, E2601, E2611.  
 
We also decided that the Plan does not have to pre-approve E2311, E2313, E2377. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if 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 for E2311, E2313, E2377. Our reviewer says that the 
enrollee has sufficient strength in the upper extremities to manage the standard power drive, and does not 
require an expandable controller or the associated electronics. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve E2311, E2313, E2377. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from December 11, 
2022, to December 20, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 178. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was treated in the hospital for a syncopal event. The enrollee had no leukocytosis, was alert 
and oriented, was without respiratory distress, wheezing, was afebrile, without hypoxia or respiratory 
complaints. The computed tomography (CT) showed airspace disease, and the enrollee was admitted for 
management. However, the enrollee showed no sputum growth of any organism, no other signs of infection of 
the lungs, and no specific confirmation of a gram-negative organism causing pneumonia. Therefore, the 
documentation does not sufficiently support the diagnosis code J15.6 - pneumonia due to other gram-negative 
bacteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from December 11, 2022, to December 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010-76 rendered on March 29, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation that showed why a second interpretation was needed. 
 
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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only." 
 
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 medical records include two 
electrocardiogram reports for the same date of service. However, the records do not include documentation to 
support that the service was performed twice on the same date of service. Therefore, the procedure code and 
appended modifier cannot be verified. 
 
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 code 93010-76 rendered on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient stay and a procedure provided 
from August 14, 2023, to August 17, 2023. 
 
You asked the Plan to waive the copayments for an inpatient stay and a procedure. You say that you feel you 
should not have to pay for this, as all issues were due to a surgery that went bad. 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 a $225 
copayment for inpatient hospital care, a $200 copayment for outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers, and a $10 copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay a $435 total copayment for an inpatient stay and a procedure ($225 + $200 + $10 = 
$435). This item/service falls within the physician/practitioner services, including doctors office visits, 
inpatient hospital care, and outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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. Therefore, we decided that the Plan does not have to waive the copayments for an 
inpatient stay and a procedure provided from August 14, 2023, to August 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate 2.5 mg tablets. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary and 
appropriate. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate 2.5 mg tablets.  
 
Benefits for the medication 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the lower complete denture (D5120) provided on May 24, 2023. We 
also decided that the Plan does not have to pay for the semi-precision attachment-placements (D6192 x 3) 
provided on May 24, 2023.  
 
  
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plans denial for payment. The Plan says that the item/services provided are not covered under the 
supplemental dental policy.  
 
We decided that the Plan has to pay for the lower complete denture (D5120) provided on May 24, 2023.  
Specifically, the contract says that the Plan covers certain dental items/services as a supplemental (extra) 
benefit. The dental item provided is indicated as a covered benefit under the supplemental dental policy. 
Therefore, we decided that the Plan has to pay for the lower complete denture (D5120) provided on May 24, 
2023.  
 
We also decided that the Plan does not have to pay for the semi-precision attachment-placements  
(D6192 x 3) provided on May 24, 2023. Specifically, the contract says that the Plan covers certain dental 
items/services as a supplemental (extra) benefit. The dental services provided in this case are not indicated as a 
covered benefit under the supplemental dental policy. Therefore, we decided that the Plan does not have to pay 
for the semi-precision attachment-placements (D6192 x 3) provided on May 24, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that this is a medically necessary treatment. 
The Plan denied your request. The Plan says there is not sufficient evidence to support the medical necessity of 
this device. 
 
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 requested device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device is a non-pneumatic sequential compression garment with sequential 
calibrated gradient pressure that is used for the treatment of lymphedema. The requested device has not been 
shown to be superior to other standard treatments for the medical condition. The studies do not indicate the Dayspring Active Compression Garment System improves an individuals function or general health compared 
to standard treatment. The requested device is not 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a non-pneumatic compression device.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the crown (D2740) for tooth number 18. We decided that the Plan does 
not have to pay for the unspecified preventive procedure (D1999).  
 
You asked the Plan to pay for the dental services provided on May 11, 2023. You say that you are appealing 
the denial. The Plan says that the criteria for coverage have not been met. 
 
We decided that the Plan has to pay for the crown (D2740) for tooth number 18.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that no medical records were provided to the IRE to support the medical 
necessity denial for the crown. Therefore, we decided that the Plan has to pay for the crown (D2740) for tooth 
number 18.  
 
We also decided that the Plan does not have to pay for the unspecified preventive procedure (D1999). 
 
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, the unspecified preventive procedure 
(D1999) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the unspecified preventive procedure (D1999). 
 
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: Favorable

 
We decided that the Plan has 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 that 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 medically necessary. Our physician reviewer found the enrollee has a progressive disease process 
that is limiting her oxygenation and documentation does support the indication for Life2000 ventilator. This 
will improve mobility and allow the enrollee to remain functionally able. Hence, there is an appropriate and 
valid indication for a Life 2000 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 been met. Therefore, we decided that the Plan has to pre-
approve a ventilator (E0466).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel provided on 
January 17, 2023, and billed with codes 81291, 81335, 81227, 81225, 81230, 81401, 81328, 81231, 81355, 
81232, 81226, 81408, 81240, and 81241. 
 
You asked the Plan to pay for the comprehensive pharmacogenetics panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the comprehensive pharmacogenetics panel provided on January 17, 2023, and 
billed with codes 81291, 81335, 81227, 81225, 81230, 81401, 81328, 81231, 81355, 81232, 81226, 81408, 
81240, and 81241.
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 enrollee needs rehabilitation so they can go 
home. The Plan denied your request. The Plan says the enrollee's medical and therapy needs could be met in a 
skilled nursing unit.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  Medically necessary care can be provided in a different 
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.