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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and trunk 
segmental pneumatic appliance. 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 a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber. 
 
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 pneumatic compressor, full leg 
segmental pneumatic appliance, and trunk segmental pneumatic appliance. Our reviewer says that the services 
are not medically necessary. Our physician reviewer found based on the medical records provided there is no 
documentation that the pneumatic compression device and associated appliances at issue in this case meet all 
Medicare criteria for medically reasonable and necessary for the enrollee. As records do not document 
lymphedema of the chest, trunk or abdomen on physical examination or a four-week trial and failure of a 
standard pneumatic compression pump, then it cannot be said that the enrollee has unique characteristics that 
would indicate a segmented pump over a standard pump or that the enrollee meets coverage criteria. 
 
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 pneumatic compressor, full leg segmental pneumatic appliance, and trunk 
segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 99231. You say that the medical records support the billing of 
code 99231. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99231. 
 
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 99231 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; 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 patient is stable, recovering or improving. Typically, 15 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 99231. Our reviewer says that the medical 
records do not support the billing of code 99231. Our reviewer found in this case, the documentation doesnt 
support code 99231 in that 2 of the 3 key components were not included in the documentation. 
 
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 99231 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99231 provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code 99213. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 99213 is bundled into payment for 
code 20610. 
 
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, we have confirmed that code 99213 is a column II code to column I code 20610; however, 99213 
was billed with a modifier.  
 
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 99213. Our reviewer says that procedure 
code 99213 does not meet criteria for payment in this case. Our reviewer found that the enrollee presented for a 
scheduled knee injection. No other problem was addressed, and no additional medical decision making was 
performed. The exam related to the knee pain is included in the injection given to treat the knee pain. The 
record does not support that a separately identifiable and distinct evaluation and management service was 
performed during this encounter. 
 
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 99213 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99213 billed for date of service January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removable denture (D6111), semi-
precision implant replacement (D6091), and a semi-precision abutment placement (D6191). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says these services 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported removable denture (D6111), semi-precision implant replacement (D6091), and a semi-
precision abutment placement (D6191).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided April 17, 2022, to April 19, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that an admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was considered medically stable for discharge on April 19, 2022 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided April 17, 2022, to April 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on June 9, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 
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 in this case, the medical records 
submitted did not support high level of medical decision making or the total time required of the code billed. 
 
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 an office visit (procedure code 99205) rendered on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support a need for cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has unspecified iron 
deficiency anemia. The enrollee has not tried and failed the Plan's required drugs, Infed and Venofer. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 10, 2023, by a 
naturopathic doctor. 
 
You asked the Plan to pay for the office visit. You say that you were advised by a plan representative that you 
would have a $50 copayment for this service. You also say that it was confirmed that the provider was in-
network. The Plan denied your request. The Plan says naturopathic services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the office visit provided on January 10, 2023, by a naturopathic doctor.  
 
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that these services are imperative because you 
are in pain. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on appeal A23133627024 when the Plan 
approved three pontics. Therefore, we decided that the Plan does not have to pre-approve retainer crowns 
(D6750 x 5).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transoral endoscopic outlet reduction procedure 
(43999). 
 
You asked the Plan to pre-approve the transoral endoscopic outlet reduction procedure. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the transoral endoscopic outlet 
reduction procedure. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records show no reason why the enrollee cannot 
undergo traditional revision surgery, or why this procedure would be more beneficial than a traditional surgical revision. 
 
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 transoral endoscopic outlet reduction procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a transoral endoscopic outlet reduction 
procedure (43999).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Yupelri. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the Part B drug is not eligible for a Part D tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier 
exception. 
 
We looked at the file and Medicare rules. The requested drug is covered by Part B Medicare and is not eligible 
for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception 
for Yupelri.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the compression stockings are 
not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87633 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for procedure code 87633. You say that this service was necessary. The Plan denied 
your request. The Plan says this code is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that 87633 is a non-covered code.  
 
 We looked at the file and Medicare rules. The service at issue is not a covered code. Based on this information, 
we decided that Medicare rules have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87633 billed for date of service September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vibone allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the use of cell-based bone graft substitutes continues to be investigated for 
various procedures, including spinal fusion and for intervertebral disc regeneration. The Plan states there is a 
lack of high-quality evidence demonstrating definitive conclusions regarding the net health benefit of cell-
based products. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vibone allograft is experimental. More research is needed. Iliac crest autograft is the gold 
standard. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vibone allograft (20930).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) provided on December 19, 2022. 
 
You asked the Plan to pay for the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm (AAA). You say that the ultrasound screening is for your existing aortic 
aneurysm. The Plan denied your request. The Plan says the enrollees benefit is limited to one AAA per 
lifetime. The Plan already received and paid for an AAA screening for date of service May 14, 2018. 
 
The Plan contract says that the Plan covers abdominal aortic aneurysm screening as a one-time screening 
ultrasound for people at risk. 
 
We looked at the file and the Plans rules. The file shows you have received the AAA maximum benefit. 
Therefore, we decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with 
image documentation, screening study for abdominal aortic aneurysm (AAA) provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure codes 96734, 96375, J2250) 
rendered on November 30, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 96374: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial 
substance/drug 
 
CPT 96375: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J2250: 
 
Injection, midazolam hydrochloride, per 1 mg 
 
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 record does not support that 
the services in question were performed as billed. The units reported for J2250 are not supported. The record 
does not state the quantity of midazolam administered; the units cannot be verified. Additionally, CPT codes 
96374 and 96375 are not supported. Although there's a check mark indicating that Toradol was given, the site 
of the infusion and the person administering it are not documented. The other medications are included in the 
procedure and sedation and cannot be reported separately. 
 
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 injection services (procedure codes 96734, 96375, J2250) rendered on November 30, 2022.