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

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on November 
28, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says chiropractic manipulative treatment is available in 
network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on 
November 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities, electrical stimulation, mechanical 
traction therapy, and therapeutic exercises provided by a chiropractor on May 8, 2023. 
 
You asked the Plan to pay for therapeutic activities, electrical stimulation, mechanical traction therapy, and 
therapeutic exercises. You say that you were told that you had to get a referral from your doctor to see a 
chiropractor that was out of network. The Plan denied your request. The Plan says The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic activities, electrical stimulation, mechanical traction therapy, and 
therapeutic exercises provided by a chiropractor on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need this because the previous one 
didn't fit you well. 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 November 28, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy, lower-level laser treatment and an x-
ray to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve message therapy, lower-level laser treatment and an x-ray. You say that the 
claim should be reprocessed. The Plan denied your request. The Plan says the services are available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
massage therapy, lower-level laser treatment and an x-ray to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for procedure code 20930. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 20930 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 29, 2022, billed 
with evaluation and management (EM) code 99215-57-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care 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 99215-57-25 is Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 29, 2022, billed with evaluation 
and management (EM) code 99215-57-25.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
April 17, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
April 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have any qualifying comorbid medical conditions, secondary 
concomitant, chronic opioid use or associated sleep disorder other than suspected OSA which would degrade a 
home sleep test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has a presumptive diagnosis 
of OSA however, no sleep study is provided. The enrollee has been diagnosed with OSA over a decade ago and 
therefore and repeat sleep study should be performed first. Titration study, if needed, should follow but the 
documentation does not support the need for split study at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 is a column II code to column I code 81455 with a modifier 
indicator of 0. The column II code is therefore not payable. Any potential/future changes to the modifier 
indicator were not in effect at the time of service or when the claim was submitted. Based on this information, 
we have decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81456 billed for date of service March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs extensive therapy 
services and wound care to give them the most optimal opportunity for a successful outcome. The Plan denied 
your request. The Plan says that they will continue to cover acute level care at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee will require at least an additional 25 days of inpatient level care. The requested 
facility will provide a more focused respiratory care than that of the enrollee's current hospital. 
 
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 LTACH services have been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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 home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee is intolerant of PAP 
therapy and will require a non-invasive ventilator for ventilatory support. You say that the enrollee is at high 
risk for hospital readmission and potentially life-threatening exacerbations. 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 the enrollee 
has COPD with hypercapnia and hypoxemia. While the enrollee was admitted for COPD exacerbation, there is 
no documented BiPAP, or non-invasive ventilator use while being in the hospital. Also, the enrollee has 
compliance issues with a CPAP but does not have documented failure of BiPAP therapy. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not support medical necessity for another diagnostic sleep study. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found this enrollee has symptoms suggestive of 
obstructive sleep apnea. There is no contraindication to a home sleep study. The enrollee does not have severe 
heart or lung disease, symptoms suggestive of parasomnias or narcolepsy, a seizure disorder, or a BMI greater 
than 45. A home sleep study would be a reasonable initial approach. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for procedure code A4223. You say that the items should be covered. The Plan 
denied your request. The Plan says procedure code A4223 is statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4223 has a status indicator of X on the Physician Fee Schedule. This means that 
procedure code A4223 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4223 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4223 billed for date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code 99024. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99024 is considered bundled 
and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service May 31, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on May 22, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that the enrollee comes in when they decide to seek addiction treatment. 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 medication assisted 
treatment, and a take home supply of methadone provided on May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare 
guidelines; care can continue to be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had little neuromuscular recovery until recently, there is no 
therapeutic advantage to transfer at this time and his needs are still quite acute. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oroantral fistula closure (D7260). 
 
You asked the Plan to pre-approve the oroantral fistula closure. You say that the service is medically necessary 
to close an opening between the mouth and sinus. The Plan denied your request. The Plan says this service is 
not a covered service under your dental plan. 
 
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 the 
oroantral fistula closure (D7260).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not medically necessary. The testing to diagnose 
obstructive sleep apnea can be safely provided with a home sleep apnea test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study 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 a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found this enrollee has symptoms suggestive of 
obstructive sleep apnea. There is no contraindication to a home sleep study. The enrollee does not have severe 
heart or lung disease, symptoms suggestive of parasomnias or narcolepsy, a seizure disorder, or a BMI greater 
than 45. A home sleep study would be a reasonable initial approach. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. Based 
on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).