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

 
We decided that the Plan does not have to pay for procedure codes J1817, 96365, 96366, 96521, and 99214 
billed for date of service March 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for diabetes. The Plan 
denied your request. The Plan says the billed services cannot be verified. 
 
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 looked at the file and the rules. We find that for CPT codes J1817, 96365, and 96366, there are more 
accurate codes that describe the services provided. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. 
 For CPT code 96521, we find that the code is not supported in the medical record. The records do not 
document a subsequent refilling of the pump. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. 
 
For CPT code 99214, we find that the code is not supported in the medical record. The records show that the 
enrollee was seen for a follow up visit. The records do not indicate a moderate level of medical decision 
making was provided. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes J1817, 96365, 96366, 
96521, and 99214 billed for date of service March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cala Trio device.
You asked the Plan to pre-approve a Cala Trio device. You say that the requested device is vital for your medical condition. The Plan denied your request. The Plan says that the requested device is not medically necessary.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Cala Trio device. Our Medical Director states that the Cala Trio nerve stimulator is a non-invasive targeted device that can reduce hand tremors in patients with Essential Tremor (ET). The documentation in the case file does not support that the enrollee in this case has ET. Our physician reviewer found that your condition does not meet criteria for coverage of a Cala Trio device.
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 Cala Trio device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cala Trio device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on July 
29, 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 Current Procedural Terminology (CPT) code 99222-25 (1 units) remains 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 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 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 documentation does support a 
comprehensive exam. However, the records do not reflect a comprehensive history or decision making of at 
least moderate complexity. Additionally, the documentation does not support CPT 99222 as a separate entity. 
 
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 initial hospital care (procedure code 99222) rendered on July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T9 and T12 kyphoplasty. 
 
You asked the Plan to pre-approve T9 and T12 kyphoplasty. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because records do not show if the enrollee 
is currently symptomatic, the enrollee's current pain scale, or if there has been any change in the enrollee's 
clinical situation. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria 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 T9 and T12 kyphoplasty. Our reviewer 
says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation 
is not evident regarding an acute or subacute osteoporotic fracture. There is no indication of a progression of 
the body height loss, progressive pain, or a severe impact on daily activities. There are no recent examinations 
to show ongoing pain and symptoms. Moreover, there is magnetic resonance imaging corroboration of other 
plausible causes of the pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T9 and T12 kyphoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve T9 and T12 kyphoplasty.
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 services are medically necessary, The Plan 
denied your request. The Plan says you do not meet the criteria for admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care level of care for left 
shoulder replacement surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are in excruciating pain and 
are limited in daily activities. The Plan denied your request. The Plan says this procedure can be performed as 
an ambulatory procedure. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found there is no documentation provided indicating medical necessity for 
inpatient level of care for this elective ambulatory procedure. An admitting physician would not reasonable 
expect that your necessary hospital care would span at least 2 midnights. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care level of care for left shoulder replacement 
surgery.
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 admission to an IRF would help you restore function 
following your brain injury due to cancer and you could at least be independent enough to try and live on your 
own. The Plan denied your request. The Plan says it does not appear that your doctors expect that you would 
improve a lot in a reasonable amount of time. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
20, 2022. 
 
You asked the Plan to pay for the services. You say that  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 99223 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 high 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 high severity. Typically, 70 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 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 documentation reflects a 
comprehensive exam. However, there was no comprehensive history or medical decision making of high 
complexity. 
 
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 initial hospital care (procedure code 99223) rendered on May 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that Eylea is medically necessary. The Plan denied your 
request. The Plan says a trial of Avastin is required before alternatives can be considered. 
 
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 Eylea. Our reviewer says that this drug 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug, 
or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve D2799 for tooth #22, 23, 24, 25, 26, 27 and D6740 for tooth #26 and 27.
You asked the Plan to pre-approve these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says on May 8, 2023, the Plan agreed to pre-approve code D6245 for tooth #24 and 25, and code D6740 for tooth #22 and 23. This exhausted the benefit for retainer crowns and pontics (D6740). Code D2799 codes did not deny for being an exhausted benefit. These codes denied because code D2799 for provisional crowns cannot be used in billing of temporary crowns, based on the description in the Code Manual of the American Dental Association. Temporary crowns are services included in the allowance of the permanent crowns.
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 services were either exhausted or incorrectly coded by your provider. Therefore, we decided that the Plan does not have to pre-approve D2799 for tooth #22, 23, 24, 25, 26, 27 and D6740 for tooth #26 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of a peri-implant defect or defects 
surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and 
closure (D6101) provided on March 7, 2023. 
 
You asked the Plan to waive the copayment for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on March 7, 2023. You also asked 
the Plan to pay for the debridement of a peri-implant defect or defects surrounding a single implant, and surface 
cleaning of the exposed implant surfaces, including flap entry and closure (D6101). You say that you are 
asking for the denial to be reviewed. The Plan denied your request. The Plan says the debridement of a peri-
implant defect or defects surrounding a single implant is not covered under the benefit package. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for debridement of a 
peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant 
surfaces, including flap entry and closure (D6101) provided on March 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955) provided on August 31, 2022. 
 
You asked the Plan to pay for the EEG. You say that you would like this claim to be reconsidered and 
processed at 100% of the allowed amount. You also say that the services were rendered at the request of the 
enrollee's surgeon for safety during surgery. The Plan denied your request. The Plan says the clinical value and 
effectiveness of an intraoperative EEG in the setting of cervical spine surgery have not been demonstrated in 
the peer-reviewed literature. 
 
The Plan follows Medicare rules. Medicare rules say that intra-operative testing may be considered reasonable 
and necessary for the indications listed in the Medicare rules section of this letter. 
 
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 EEG. Our reviewer says that based on 
the medical records provided there is no documentation that the EEG at issue in this case meets all Medicare 
criteria for medically reasonable and necessary for the enrollee. Our physician reviewer found the provided 
records in this case do not document necessity of the EEG. Our reviewer also found that review of the current 
peer-reviewed medical literature does not document that use of EEG during cervical spine surgery results in 
health benefits to patients. 
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on August 31, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable supplies (code A0382) provided on May 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical record supports medical necessity. 
The Plan denied your request. The Plan says the services are included in the base ambulance rate. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment is included in the payment rate for the transport. Therefore, we decided 
that the Plan does not have to pay for disposable supplies (code A0382) provided on May 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found studies have shown SBRT to be safe and effective for pancreatic cancer. It does not appear that 
SBRT is necessarily superior to conventionally fractionated radiation for unresectable (as the case for this 
enrollee), although is an accepted treatment modality for pancreatic cancer in general.  The standard medical 
necessity criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiotherapy (SBRT).  
 
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 procedure code 87798 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for procedure code 87798. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says these services are not supported in the medical record as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 procedure code 87798 Our reviewer says 
that the records provided do not support the 13 units of code 87798 reported. Our physician reviewer found the 
laboratory report does not include documentation to support 4 of the 13 units billed. Results for the following 
tests are supported in the laboratory report, Bordetella Panel; Bordetella pertussis, Bordetella homesii, Coxiella 
burnetiid, haemophiles influenzae, klebsiella pneumoniae, Moraxella catarrhalis, streptococcus pneumoniae, 
pneumocystis jirovecii. In this case, the claim denied correctly as four units cannot be verified. 
 
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 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87798 billed for date of service January 27, 2023.