Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45385) provided on August 5, 2022. 
 
You asked the Plan to pay for the colonoscopy. You say that you would like this claim to be reconsidered for 
payment of code 45385. The Plan denied your request. The Plan says the billing of code 45385 is not 
supported. The Plan also says the medical records do not indicate that snare technique was performed.  
 
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 45385 is a colonoscopy, flexible; with removal of 
tumor(s), polyp(s), or other lesion(s) by snare technique.  
 
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 colonoscopy. Our reviewer says that the billing of this 
procedure code is not supported. Our reviewer found that the procedure report documents "There was a 4 mm polyp of the ascending colon s/p cold biopsy forceps polypectomy with complete removal and retrieval. For 
CPT 43585, the provider examines the colon and rectum using a colonoscope, a long, thin flexible tubular 
instrument with a light source and camera. He removes one or more tumors, polyps, or other lesions with a 
snare, a wire loop that he passes around the base of the lesion and tightens it until the wire cuts through the 
lesion. In this case, the procedure report does not include sufficient documentation to verify the procedure 
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 colonoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for the colonoscopy (45385) provided on August 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug regimen of Keytruda (J9271), gemcitabine 
(J9201), and ondansetron (J2405). 
 
You asked the Plan to pre-approve the drug regimen. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the use of Keytruda, gemcitabine, and 
ondansetron for the enrollees condition is not FDA approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug regimen. Our reviewer says 
that the drug regimen is not medically necessary. Our physician reviewer found that the drug combination of Keytruda, gemcitabine, and ondansetron is not approved for the enrollee's diagnosis. The use of this drug 
regimen is not supported by the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal.  
 
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 drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the drug regimen of Keytruda (J9271), gemcitabine (J9201), and ondansetron (J2405).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 7, 
2023, to March 8, 2023.  
You asked the Plan to pay for SNF care. You say that the records provided support the SNF services in dispute. 
The Plan denied your request. The Plan says the criteria for coverage have not been met.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was near baseline and did not require daily skilled therapy or nursing 
services throughout the period in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 7, 2023, to March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 48 additional routine transportation trips. 
 You asked the Plan to pre-approve the additional transportation trips. You say that you need the additional 
transportation for medical needs and your provider can vouch for this. The Plan denied your request. The Plan 
says you have exhausted your 24 one-way rides to other healthcare-related locations for 2023. 
 
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 24 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 medical needs. 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 48 additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electromyography provided on November 10, 2022. 
 
You asked the Plan to pay for the electromyography. You say that the services were medically necessary. The 
Plan denied your request. The Plan says pseudoarthrosis after fusion or arthrodesis is not a listed diagnosis 
code per the Medicare local coverage article. 
 
The Plan must follow Medicare rules. Medicare rules say pseudoarthrosis after fusion or arthrodesis are not a 
listed diagnosis code. 
 
We looked at the file and Medicare rules. The file show that pseudoarthrosis after fusion or arthrodesis are not 
a listed diagnosis code per the Medicare local coverage article. Based on this information, we decided that 
Medicare rules for coverage of the electromyography have not been met. Therefore, we decided that the Plan 
does not have to pay for electromyography provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for housekeeping services provided from December 12, 2022, to 
December 15, 2022. 
 You asked the Plan to pay for the housekeeping services. The Plan denied your request. The Plan says 
housekeeping services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the housekeeping services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for 
housekeeping services provided from December 12, 2022, to December 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services.  
 
You asked the Plan to pre-approve physical therapy services. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says one evaluation visit has been approved; the 
remaining treatment visits are denied as not medically necessary.  
 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 physical therapy services. 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 enrollee may benefit from passive stretching and a 
repetitive exercise program for strengthening but these are not skilled services. The goals are not clear. The 
enrollee does not require unique skills of a therapist to improve or restore function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0466) provided from January 27, 
2023, to April 27, 2023. 
 
You asked the Plan to pay for the home ventilator. You say that the home ventilator was medically necessary. 
The Plan denied your request. The Plan says a home ventilator was not medically necessary. 
 
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. 
 
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 home ventilator. Our reviewer says that the home ventilator was not medically necessary. Our physician reviewer found that there is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. The home ventilator was prescribed on December 21, 
2022, following a hospitalization. There is no documentation of chronic carbon dioxide (CO2) retention with 
an arterial blood gas (ABG) analysis done while stable. A compliance download covering March 8, 2023, to 
April 6, 2023, showed the device was being used for at least four hours a day for only 20% of the days. This is 
insufficient use of the home ventilator for significant benefit.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pay for the home ventilator (E0466) provided from January 27, 2023, to April 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization (37225, 37229). 
 
You asked the Plan to pre-approve endovascular revascularization. You say that the enrollee has 75% stenosis 
in the left popliteal artery. The Plan denied your request. The Plan says this procedure is not medically 
necessary.  
 
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 endovascular revascularization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the documentation does not adequately describe the details of 
symptoms to determine that the enrollee is experiencing lifestyle limiting claudication. There is no evidence of 
efforts at conservative treatment. As endovascular interventions, particularly at the level of the popliteal artery 
and distally have a high chance of doing more harm than good, clarity with respect to indications is critical. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular revascularization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve endovascular revascularization (37225, 37229).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 01, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that it is the responsibility of the facility to 
obtain prior authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on May 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an MRI provided on June 15, 2022. 
 
You asked the Plan to waive the cost for an MRI. You say that you do not owe the charge you are being billed 
for. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible, which applies to an MRI, 20% coinsurance for 
medical supply, including chemical agents used in certain diagnostic procedures, and a $65 copayment 
radiological diagnostic services, not including x-rays.  
 
 
  You have been asked to pay $1,101.34 for an MRI. This total includes a $1,000 deductible, a $65 copayment 
for diagnostic radiology and $36.34, which is 20% of the allowed amount for a chemical agent used in the MRI 
procedure ($181.71 allowed x 20% = $36.34). The item or service you asked the Plan to waive the cost for falls 
within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible. This cost sharing is a contractual obligation that had 
not been met at the time an MRI was received on June 15, 2022. Therefore, we decided that the Plan does not 
have to waive the cost for an MRI provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with no power 
options. 
 
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 services cannot be approved with the requested code. 
 
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 Medicare rules. The file shows that the Group 3 PWC is being requested with code 
E1399. This code is not appropriate for a Group 3 PWC and cannot be approved. Given that the PWC cannot 
be approved, the requested accessories are also not approved. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with no power options.
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 you need an IRF admission. The Plan denied your 
request. The Plan says your condition does not meet the criteria 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an 
intensive rehabilitation therapy program as it can be handled on a different level of care. Also, there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 the practitioner services provided on March 30, 2023, billed 
with procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says the procedure codes 96365-59, 96366-59, and 96521 are 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug), additional hour. The definition of 
code 96521 is refilling and maintenance of portable pump. 
 
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 practitioner services. Our reviewer says that the billing of 
these procedure codes is not supported. Our reviewer found that the medical record describes the insulin 
infusion of Novolin R for an outpatient (96365, 96366). In this case, there are more descriptive procedure 
codes to support these services. The medical record also includes a physician order for the refilling and 
maintenance of a portable pump (96521); however, it does not include documentation of the procedure having 
been performed. 
 
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 practitioner services have not been met. Therefore, we decided that the Plan 
does not have to pay for the practitioner services provided on March 30, 2023, billed with procedure codes 
96365-59, 96366-59, and 96521.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT services provided from December 6, 
2022, to December 30, 2022. 
 
You asked the Plan to waive the copayment for PT services. You say that you exceeded you MOOP and should 
not be responsible for this claim. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each physical therapy visit.  You have been asked to pay a $213.32 copayment for PT services. This total is less than the standard 
copayment for PT services because your MOOP was met with the processing of this claim. This item/service 
falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for PT services provided from December 6, 2022, to December 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the provided records support the need for IRF care. 
The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crowns (D2740 x 2) and the resin-
based composite-three surfaces, anterior (D2332) provided on April 13, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items at issue are not covered by 
Medicare.   
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The dental items you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental items that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic crowns (D2740 x 2) and the resin-based composite-three surfaces, anterior (D2332) provided 
on April 13, 2023.