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

 
We decided that the Plan has to pay for dialysis services and procedures provided from February 1, 2021, to 
February 26, 2021. 
 
You asked the Plan to pay for dialysis services and procedures. You say that the dialysis services were 
medically necessary. The Plan denied your request. The Plan says that the information submitted is insufficient 
for processing per CMS End Stage Renal Disease billing guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a coding rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for dialysis services and procedures 
provided from February 1, 2021, to February 26, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a cardiology consultation. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are multiple cardiologists within the primary network that all meet Medicare time 
and distance requirements. 
 
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 
an out-of-network referral for a cardiology consultation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 pre-approve 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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pre-approve a continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 9, 2023, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the service is separately payable. The Plan 
denied your request. The Plan says out-of-network services are not payable. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on January 9, 2023, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay the in-network rate for the office visit provided on November 30, 2022. 
 
You asked the Plan to pay the in-network rate the office visit. You say that the claim was processed as out-of-
network. You say that the provider is in-network. You also say that this claim should be reprocessed at the in-
network rate. The Plan denied your request. The Plan says that the claim was correctly processed at the out-of-
network rate. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's website indicates that the provider in this case is a 
network provider. Therefore, we decided that the Plan has to pay the in-network rate for the office visit 
provided on November 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 
19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the syringe with needle for external insulin pump (A4232). 
 
You asked the Plan to pay for the syringe with needle for external insulin pump. You say that you will be 
running out of supplies and will not be able to get your insulin into your body. The Plan denied your request. 
The Plan says A4232 is not covered by Medicare in any payment system. 
 
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 find that CPT code A4232 is not supported in the medical record. Specifically, A4232 is 
bundled into CPT code A4224, supplies for maintenance of insulin infusion catheter, per week, which has already been approved by the Plan. Based on this information, we decided that Medicare rules for coverage of 
the syringe with needle for external insulin pump have not been met. Therefore, we decided that the Plan does 
not have to pay for the syringe with needle for external insulin pump (A4232).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not show that 3 additional home health physical therapy sessions are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that the documentation submitted supports the enrollee's need 
for this service. The Plan denied your request. The Plan says the requested RFA is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary when the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary 
(index) pain. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had at least 80% relief from the previous blocks. Therefore, the reviewer found that 
the requested RFA is not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service December 
9, 2022. 
 You asked the Plan to pay for the billed services. You say that the service was medically necessary and should 
be paid separately. The Plan denied your request. The Plan says the documentation does not support the use of 
the modifier. 
 
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 find that CPT code 99213-25 is not supported. Specifically, the medical records do not show that the 
evaluation and management service was a significant and separately identifiable from minor procedure code 
20610. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213-25 billed for date 
of service December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyperbaric Oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record provided does not document 
the presence of a condition for which coverage is available under the rules. The elements of the coverage 
criteria are not satisfied. The requested service is not 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyperbaric Oxygen (HBO) therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine tablet.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are 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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of back pain is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that a total knee arthroplasty is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a total knee arthroplasty 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 a total knee arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative-care measures is not evident in the case record. No compelling 
rationale is presented nor extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthroscopic procedure of right knee. 
 
You asked the Plan to pre-approve an arthroscopic procedure of right knee. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are 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 an arthroscopic procedure of right knee. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. You reportedly refuse conservative 
treatments including medications and injections. The course of physical therapy is not clearly documented. 
Moreover, the specific procedure is not clearly documented as the provider indicated she was not indicated for elective knee surgery as the risks of surgical intervention outweigh the benefits. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an arthroscopic procedure of right knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an arthroscopic procedure of right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetics to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve lower limb prosthetics. You say that this is needed so the enrollee can walk. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the needed 
prosthetics can be obtained within the Plan 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 
lower limb prosthetics to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99401 billed for dates of service 
August 17, 2022, to August 18, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are not 
eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The file shows that code 99223 was billed for date of service August 17, 2022. 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 a comprehensive history; A comprehensive examination; and medical decision making 
of high complexity. We find that CPT code 99223 is not supported in the medical record. The records show 
that the enrollee presented for lower back pain extending into the lower extremities. The enrollee was in no 
acute distress denying shortness of breath, chest pain, fever, or numbness. The records do not show that 
medical decision making of high complexity was provided.   
 
The file shows that code 99401 was billed for date of service August 18, 2022. We find that code 99401 has a 
status indicator of N. Code 99401 is not covered be Medicare. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99223 and 99401 billed for dates of service August 17, 2022, to August 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 00142-QK-QS-P2 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for code 00142-QK-QS-P2. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied.  
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 3, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 00142-QK-QS-P2 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 00142-QK-QS-P2 billed for date of service 
October 6, 2022.