Persius/hicric huggingface dataset:
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 the enrollee is unable to use glucose meter because 
of the pain in their hands. 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).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
17, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. 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. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on July 17, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 40 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for your 
appointments and to and from your dialysis treatments. The Plan denied your request. The Plan says you have 
exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your appointments and to and from your dialysis appointments. Based on this information, 
we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve 40 additional routine transportation trips 
(A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of semi-precision abutments (D6191 x 2) 
and semi-precision attachments (D6192 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you would not have extracted your teeth if 
you knew that there was no coverage for dental implants. The Plan denied your request. The Plan says these 
services are not covered benefits 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 
placement of semi-precision abutments (D6191 x 2) and semi-precision attachments (D6192 x 2).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit while under hospice care (99285) 
provided on December 16, 2022. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as the enrollee 
disagrees with the denial. 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 an emergency room visit while under hospice care (99285) 
provided on December 16, 2022.
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 May 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was a 
medical necessity and he should have been transported but he wasn't. You also say that had he gotten to the 
hospital sooner it would have been a different outcome. 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 May 28, 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 May 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing - four or more 
teeth per quadrant (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the provider split the cleanings in a 
different appointment. You also say that you are asking for a reconsideration due to the medical necessity. The 
Plan denied your request. The Plan says your benefit for the requested periodontal scaling and root planing 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 service was exhausted on date of service August 30, 2023. Therefore, we 
decided that the Plan does not have to pre-approve the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning, all four quadrants (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning, all four quadrants. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
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 deep 
gum and root cleaning, all four quadrants (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies; 13 or more studies (95913) and 
the needle electromyography testing (95886) provided on August 3, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that this type of provider is not allowed to bill 
for these services.   
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the nerve conduction studies; 13 or more studies (95913) and the needle 
electromyography testing (95886) provided on August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on April 26, 2023, and June 1, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings are a 
necessary treatment and care for your diagnosis of Lymphedema. You also say that you have submitted 
invoices for the required treatment and supplies. The Plan denied your request. The Plan says this item is not 
needed as a surgical dressing.  
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 pay for the compression 
stockings identified with code A6549 that were issued on April 26, 2023, and June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontics, retainer crowns, and post and core in addition to 
crown (D6245, D6740, D2952) provided on April 27, 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 crowns and pontics has 
already been exhausted on the appealed claim. Additionally, this benefit does not include post and core in 
addition to 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 item or service was exhausted on date of service April 27, 2023. 
Additionally, this benefit does not include post and core in addition to crowns. Therefore, we decided that the 
Plan does not have to pay for pontics, retainer crowns, and post and core in addition to crown (D6245, D6740, 
D2952) provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation (D4921) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the procedures are medically necessary 
because you are unable to take antibiotics to prevent infection. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the gingival irrigation is not covered by the 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 
gingival irrigation (D4921) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) (K0862), power 
seating system (E1007), leg rest (E1012), and electronic connection (E2311). 
 
You asked the Plan to pre-approve a group 3 PWC and additional features. You say that the items are 
medically necessary. The Plan denied your request. The Plan says there is no documentation that of e a 
neurological condition, myopathy, or congenital skeletal deformity that caused the enrollee's mobility problem. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or  
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair (PWC) (K0862), power seating system (E1007), leg rest (E1012), and electronic 
connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) rendered on June 20, 2023.

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 criteria was not met for the requested CPT 99214.

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 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 provided documentation from this date describes the patient with severe degeneration of the knee joint based on x-ray findings and examination and was treated with steroid injections to both knees and started on non-steroidal anti-inflammatory drugs (NSAIDs) with plans to follow-up as needed. The enrollee was stable and did not have any complexity or plans for invasive treatment. The documentation supports an appropriate history and physical; however, it does not support a moderate level of medical decision making or that the encounter took 30-39 minutes as required for CPT 99214. 

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 evaluation and management services (procedure code 99214) rendered on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of 
the head. 
 
You asked the Plan to pre-approve the CTA scan. You say that the services are medically necessary for the 
enrollee's symptoms and due to their family history of aneurisms. The Plan denied your request. The Plan says 
the scan 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 the CTA scan. Our reviewer says that 
the CTA scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has migraine headaches. The provided records do not indicate the medical necessity or reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
 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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomographic angiography (CTA) scan of the head.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services. 
 
You asked the Plan to pre-approve transportation services. You say that the services are medically necessary, 
and you were not aware of the Healthy at Home benefit. The Plan denied your request. The Plan says its been 
more than 30 days since you were discharged. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the request is made within 30 days from post discharge date.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transportation services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee still requires physical 
therapy services to aid in their ability to return to prior level of function. The Plan denied your request. The 
Plan says the enrollee has reached reasonable goals for daily tasks and their progress has slowed and they can 
now use a home exercise program.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested physical therapy is generally accepted as a 
specific and effective therapy for hip and low back pain and well as reduced mobility due to a hamstring injury. 
The enrollee has had 12 sessions of physical therapy and is currently making gradual progress. An additional 
12 sessions of physical therapy that was approved by the Plan should be sufficient to allow for additional 
progress and transition to a home exercise program. Therefore, the remaining 12 visits of physical therapy 
being requested are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy (PT) visits.
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 you do not agree with the Plan's 
decision to deny coverage for the non-invasive ventilation machine that you have been using since September 
1, 2023. You say that the non-invasive ventilation machine is medically necessary. 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 you have 
chronic respiratory failure from chronic obstructive pulmonary disease. However, the documentation does not 
contain sufficient detailed information in the medical records to justify the treatment selected. Also, you can be 
treated with a BiPAP machine with AVAPS capability and such failure of such a device has not been 
documented. Therefore, the elements of the coverage criteria are not satisfied, and the requested service cannot 
be recommended. 
 
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: 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 acute rehabilitation is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.