Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the enteral feeding supply kit and enteral formula (B4035 and B4150) 
provided from May 18, 2023, to May 31, 2023. 
 
You asked the Plan to pay for the enteral feeding supply kit and enteral formula. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are 
not covered as billed. 
 
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 denial rationale is that the POS code used should be 31. As cited in the 
Rules section, POS code 31 is appropriate for enrollees in a Part A covered SNF stay, with 32 being used for 
those in a noncovered stay. Enteral supplies are separately billable during a noncovered stay only. As such, 
using POS 32 is valid in this case. The Plan provided no evidence to support that POS 31 is the correct code, 
such as a paid SNF claim showing that Part A coverage was provided for this admission. Therefore, we decided 
that the Plan has to pay for the enteral feeding supply kit and enteral formula (B4035 and B4150) provided 
from May 18, 2023, to May 31, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23600 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says the documentation does not include a closed reduction.  
 
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 23600 is closed treatment of proximal humeral (surgical 
or anatomical neck) fracture; without manipulation. 
 
 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 billed services. Our reviewer found that the procedure 
report documents the enrollees care consisting of an arm sling. In order to submit a claim for fracture care, the 
treatment must meet the definition of restorative care and must involve more than merely splinting the fracture 
after straightening the limb. There is a more specific code to report for application of sling. Therefore, the 
billed code is 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 the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 23600 billed for date of service June 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Levocarnitine and Cyanocobalamin. 
 
You asked the Plan to pay for Levocarnitine and Cyanocobalamin. You say that this is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of Levocarnitine and 
Cyanocobalamin (vit B12) in the setting of bilateral lower leg pain have not been demonstrated in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pay for Levocarnitine and Cyanocobalamin. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the review indicates 
that the clinical value and effectiveness of Levocarnitine and Cyanocobalamin (vit B12) in the setting of 
bilateral lower leg pain have not been demonstrated in the peer-reviewed literature This treatment is not 
considered a standard of care. The review has determined that the documentation does not support that the 
Levocarnitine and Cyanocobalamin is medically reasonable and necessary for the patient.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Levocarnitine and Cyanocobalamin have not been met. Therefore, we decided 
that the Plan does not have to pay for Levocarnitine and Cyanocobalamin.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Zilretta injections. 
 
You asked the Plan to pay for Zilretta injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 pay for Zilretta injections. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the documentation supports that Zilretta is 
medically reasonable and necessary for the patient and is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injections have been met. Therefore, we decided that the Plan has to pay 
for Zilretta 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87481, 87653, 87563, 87551, 
87556, 87640, 87651, 87801, 87561, 87500, and 87641) provided on March 13, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, 87563, 87551, 87556, 87640, 87651, 
87801, 87561, 87500, and 87641. You say that you would like the Plan to reconsider their denial of payment. 
The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 codes 87798, 87481, 87653, 87563, 87551, 87556, 87640, 87651, 87801, 87561, 87500, and 
87641 are not supported in the medical record. Specifically, a panel was performed and there is a more 
appropriate singular code for the services. 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 the 
panel testing (87798, 87481, 87653, 87563, 87551, 87556, 87640, 87651, 87801, 87561, 87500, and 87641) 
provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJI. 
 
You asked the Plan to pre-approve a SIJI. You say that the requested procedure is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements necessary for the 
requested procedure to be approved. 
 
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 a SIJI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of at least three positive findings with provocative maneuvers: 
FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI Distraction and Yeoman Tests, and 
low back pain persists despite a minimum of four weeks of conservative therapies. The review has determined 
that the enrollee does not meet the LCD 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 a SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a SIJI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs the ventilator to 
prevent respiratory distress and decline.  The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that although the 
enrollee has a diagnosis of COPD, there are no pulmonary function tests to assess the severity of the COPD. 
Also, there is no diagnosis of thoracic restrictive disease or neuromuscular disease. Furthermore, there is no 
arterial blood gas analysis (ABG) done while stable to document chronic carbon dioxide retention. If that is 
present, the enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient. Medicare does not 
cover a home ventilator when used at settings that can be provided with a 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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 24, 2023, 
to May 22, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. 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 subsequent nursing 
facility care provided on March 24, 2023, to May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (64590). 
 
You asked the Plan to pre-approve insertion or replacement of peripheral or gastric neurostimulator pulse 
generator or receiver, direct or inductive coupling. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is experimental for treating refractory urge urinary incontinence and is not 
covered. 
 
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 insertion or replacement of peripheral 
or gastric neurostimulator pulse generator or receiver, direct or inductive coupling. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered to be an experimental treatment for overactive bladder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of peripheral or gastric neurostimulator pulse generator 
or receiver, direct or inductive coupling have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, 
direct or inductive coupling (64590).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
21, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have submitted the documentation and would 
like the claim processed accordingly. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve CT scan of the abdomen and pelvis. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan of the abdomen and pelvis. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the review of 
records shows the patient claims to have lost significant weight recently but there is no documentation of how 
much weight and over how long a period. The records show unchanged weight between July and August, 2023. 
No ultrasound results are in the chart. The LCD rules require a loss of at least 10 pounds or 5% of body weight 
over the past 6 months to qualify for CT The medical necessity of the requested CT abdomen and pelvis has 
not been established in the records 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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3908) provided on March 31, 2023. 
 You asked the Plan to pay for the wrist hand orthosis (L3908). You say that you included the GW modifier on 
the claim because service was not related to the enrollee's terminal condition. The Plan denied your request. 
The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the wrist hand orthosis (L3908) provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve the injection. You say that you cannot walk and have been instructed to go 
to the gym and workout. You say that you have tried physical therapy which has not helped and due to you not 
being able to move is causing you to be depressed. The Plan denied your request. The Plan says a platelet rich 
plasma injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
platelet rich plasma injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 25, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
afraid you had injured your neck following a previous neck surgery on July 7, 2023 and your several attempts 
to reach your surgeon's office were unsuccessful. You also say that it was suggested to you to call 911 after 
speaking with the hospital emergency room staff. The Plan denied your request. The Plan says these services 
are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 25, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on July 06, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting a reconsideration of the 
denied claim. 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 skilled nursing facility 
provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, 2D oral/facial photographic image, 
periodontal scaling and root planing. and gingival irrigation (D4921, D0350, D4342, D0210) provided on June 
23, 2023. 
 
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 your benefit for the requested item or service has 
already been exhausted. Additionally, this benefit does not include 2D oral/facial photographic images, 
periodontal scaling and root planing. or gingival irrigation. 
 
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 intraoral x-rays was exhausted on date of service June 23, 2023 (D0210). Additionally, 
this benefit does not include 2D oral/facial photographic images, periodontal scaling and root planing. or 
gingival irrigation. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray, 2D 
oral/facial photographic image, periodontal scaling and root planing. and gingival irrigation (D4921, D0350, 
D4342, D0210) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia  first 15 minutes (D9222), 
and deep sedation/general anesthesia  each subsequent 15 minute increment (D9223) provided on June 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you get anxious and need the sedation for the 
dental services to be performed. The Plan denied your request. The Plan says your benefit for the requested 
item or service $4,000 dollar limit was met. 
 
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 deep sedation/general anesthesia services was exhausted on date of service May 15, 
2023, and June 21, 2023. Therefore, we decided that the Plan does not have to pay for deep sedation/general 
anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  each subsequent 15 minute 
increment (D9223) provided on June 21, 2023.