Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested items. The Plan denied your request. The Plan says this service is not covered under your 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. Crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) are not covered under the Plans dental 
benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2740 and D2950 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crown - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. The enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-plan referral for continuation of oncology 
services at Clovis Community Medical Center. 
 
You asked the Plan to pre-approve continuation of services for oncology. You say that the enrollee is going 
through cancer and dialysis, and you feel this is putting your mothers health at risk. You do not think it will be 
a smooth transition. The Plan denied your request. The Plan says the enrollee was referred out to the requested 
facility due to access issues and continued her treatment at the external facility. Access issues within the Plan's 
network facility has now been resolved and the enrollee is being transitioned back within the plan. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continuation of services for oncology have not been met. Specifically, the records show that there 
were access issues with the network facility which have now been resolved. The records also show that the 
referral for the out of network facility was expiring on July 31, 2023. The enrollee has an appointment with the 
network facility on August 8, 2023. Therefore, we decided that the Plan does not have to pre-approve an out-
of-plan referral for continuation of oncology services at Clovis Community Medical Center.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (22899 and C1713). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says more studies are needed to show Minuteman Procedure is safe and 
effective. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure (22899 and C1713).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits for ophthalmological services (92002, 
92012x2, 92285, 99205, 99215x2) with an optometrist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that your current four pairs of prisms for different 
distances that were made two years ago do not compensate like they did three years ago. The medical condition 
specialization is not available from local doctors. The Plan denied your request. The Plan says you must use 
network providers for medical services. The service is available with a community level provider. 
 
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 
office visits for ophthalmological services (92002, 92012x2, 92285, 99205, 99215x2) with an optometrist 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 an additional unit for procedure codes 51785 and 95861 
rendered on June 8, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 51785: 
 
Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
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 procedure report does not 
include any documentation to support the reporting of the additional units. When reporting additional units 
above the allowable, the documentation should support this. 
 
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 an additional unit for procedure codes 51785 and 95861 rendered on June 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
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 Imfinzi. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found that Imfinzi is FDA-approved for the 
enrollee's diagnosis in combination with gemcitabine and cisplatin for biliary tract cancers. The documentation 
supports that Imfinzi is safe and effective and otherwise reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have been met. Therefore, we decided that the Plan has to pre-approve 
Imfinzi (J9173).  
 
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 pay for procedure code 99309-25 rendered on November 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99309-25 remains not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99309 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: detailed 
interval history; detailed exam; medical decision making of moderate complexity in addition to debridement 
services provided on same date of service." 
 
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 medical records do not 
contain any documentation of evaluation and management, which would include an appropriate history, exam, 
and medical decision making. Modifier -25 is not supported, as the report does not include any documentation 
of a separate service from the wound care procedures that were 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99309-25 rendered on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. This enrollee may benefit from bilevel positive airway pressure (BiPAP), with or without average 
volume-assured pressure support (AVAPS), during sleep as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
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 the records provided support the need for 
LTACH care.  The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 is currently undergoing treatment at an acute care hospital (ACH) 
following a stroke.  The enrollee was intubated/ventilated and eventually received a tracheotomy and feeding 
tube.  The enrollee has been weaned from the ventilator.  There is no evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH 
until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level 
of care for any ongoing long term care needs. 
 
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: 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 inpatient rehabilitation so they can help 
you. The Plan denied your request. The Plan says you do not meet the guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you meet criteria for admission to an acute inpatient rehabilitation facility. 
You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care.  
The Plan denied your request. The Plan says IRF care is not medically necessary.  
 
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 enrollee's history does not support the level of care requested.  
Although documentation supports the need for rehabilitation, it does not support the need for complex nursing, 
medical management, and rehabilitative needs. Although physical and occupational therapy is warranted, 
documentation does not support the need for multiple therapy disciplines, speech-language, or 
prosthetic/orthotics services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. You asked the Plan to pre-approve a Freestyle Libre 2. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been 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. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia Based on this information, we decided that Medicare rules for coverage 
of a Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on January 14, 2023. 
 You asked the Plan to pay for the air ambulance services. You say that the air ambulance services were 
medically necessary.  The Plan denied your request. The Plan says the information submitted does not support 
this level of service.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found multiple closer facilities 
should have been available in the Green Bay area.  There is no documentation showing that these closer 
facilities were not available.  As such, air ambulance transport to Milwaukee is not shown to have been 
medically necessary and reasonable. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 
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 pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in a volume assured pressure support (VAPS) mode which is 
a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).