Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mastectomy bra, and the silicone or equal breast 
prosthesis to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the mastectomy bra, and the silicone or equal breast prosthesis. You say that 
this is supported in the records. The Plan denied your request. The Plan says enrollees must receive their care 
from a network 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 
the mastectomy bra, and the silicone or equal breast prosthesis 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 nursing facility visit codes 99306 and 99497 provided on 
September 30, 2022. 
 
You asked the Plan to pay for 99306 and 99497. You say that these were emergency services. The Plan denied 
your request. The Plan says these codes 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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit. The CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
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 99306 and 99497. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found the medical records provided do not include sufficient 
documentation to validate code 99306. The records do not include sufficient documentation to validate code 
99497. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99306 and 99497 have not been met. Therefore, we decided that the Plan does 
not have to pay for nursing facility visit codes 99306 and 99497 provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of continuous positive airway pressure 
(CPAP) device (E0601).  
 
You asked the Plan to pre-approve a CPAP device. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the medically necessary 
criteria was not met for this service. 
 
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 CPAP device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has been on CPAP for a diagnosis of obstructive sleep apnea since 2019. 
Continued coverage of the device was denied because there was no face-to-face visit.  However, this does not 
apply because the enrollee has been on CPAP for years. Recent compliance with the device was shown to be 
100%. However, polysomnography in 2018 showed a normal apnea-hypopnea index (AHI) of 1.9, and 
respiratory disturbance index (RDI) of 1.9, indicating no diagnosis of obstructive sleep apnea. The denial is 
upheld because there is no documentation that the enrollee has obstructive sleep apnea. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuation of continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheterization procedure (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that cardiac catheterization is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says cardiac catheterization 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 cardiac catheterization. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee had an electrocardiogram (ECG) which did not show ischemia. A non-invasive 
workup has not been performed. The provided documentation does not reveal the rationale for the requested 
invasive imaging study. Guidelines do not support a need for cardiac catheterization in this 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheterization procedure (93458).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for AlloSure Kidney (81479) provided on November 10, 2021.  
 
You asked the Plan to pay for AlloSure Kidney. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that the requested AlloSure testing is considered experimental and 
investigational when used for surveillance.  
 The Plan follows Medicare rules. Medicare rules say that this test is covered when the criteria in the rules 
section of this letter are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for AlloSure Kidney. Our reviewer says that the 
criteria for coverage are met. Our physician reviewer found that Allosure is a method to detect the likelihood of 
acute rejection. Acute rejection often is not apparent until after sometimes irreversible damage has been done. 
The only other way to screen for kidney transplant rejection is biopsy. A kidney biopsy is an invasive 
procedure that carries some risk to the enrollee. The Allosure test is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of AlloSure Kidney have not been met. Therefore, we decided that the Plan has to 
pay for AlloSure Kidney (81479) provided on November 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you were obligated to complete the analysis. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim crowns (D2799) for tooth #23, #24, #25, and 
#26. 
 
You asked the Plan to pre-approve the dental services. You say that you need the temporary crowns done first 
and then the permanent crowns after. The Plan denied your request. The Plan says temporary crowns are 
services included in the allowance of the permanent crowns; therefore, the denial for the interim crowns was 
correct. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our reviewer says 
that the interim crowns (D2799) are not medically necessary for teeth #23, #24, #25, and #26. Our physician 
reviewer found that the teeth had been treatment planned for crowns, and the provider had submitted for 
temporary crowns as well for the same teeth. Teeth being prepared do usually require temporization until the 
final crowns are inserted. The code presented is to be used for covering a tooth that has an unsure prognosis 
that may make a final crown impossible, or there is other work that needs to be completed to allow for the final 
crown. There is no indication that the temporary crown would be needed in this instance other than to cover the 
tooth until a final crown is inserted. 
 
The Plan will not cover temporary crowns under the submitted code where the tooth is being normally prepared 
for a final crown. The temporization of a tooth is an inclusive charge where a crown is involved. Separate 
charges for temporization are not allowed as it is a component of the crown charge. As there is no indication of 
any issue that would require there be temporization for the purpose of determining restorability of the teeth or 
overall treatment plan, there would be no separate coverage for standard temporary crowns. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the interim crowns (D2799) for tooth #23, #24, #25, and #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 08, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (code 99202) billed for date of service August 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that one exam per year is a benefit of your plan. The 
Plan denied your request. The Plan says that the office visit does not fall under the routine chiropractic benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the office visit (code 
99202) billed for date of service August 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T11 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T11 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve T11 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found there is no documented trial 
of fracture bracing. More conservative measures needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T11 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T11 kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services (99223) provided on December 8, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with an inappropriate place of service. 
 
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 rules also say that the place of service (POS) code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital 
inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported 
regardless of where the face-to-face service takes place. 
 
We find that payment for CPT code 99223 is not supported in the medical record. Specifically, the claim was 
billed with POS 22. It is inappropriate to bill an outpatient POS code with an inpatient CPT code. 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 the inpatient services (99223) provided on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
does not show any modic changes. The requested Intracept procedure is not reasonable or medically necessary 
based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the Plan requires a trial of Orthovisc or Supartz FX before it will approve Euflexxa. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found the 
enrollee has not tried and failed one of the Plan's preferred drugs of Orthovisc or Supartz FX. The record does 
not show that these drugs would likely be less effective and/or have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor. You asked the Plan to pre-approve the FreeStyle Libre kit 2 sensor. You say that the enrollee has tried all 
medications which has made them sick. You also say that the CGM will help to monitor their blood sugar. The 
Plan denied your request. The Plan says the enrollee is not on insulin and does not have documentation of 
problematic hypoglycemia. A CGM is not covered under current Medicare criteria.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre kit 2 sensor. Our 
reviewer says that the FreeStyle Libre kit 2 sensor is not medically necessary. Our physician reviewer found 
coverage criteria for CGM require either insulin use or low blood glucose sugar. The enrollee is not taking any 
medications for diabetes mellitus and we are not told of low blood glucose sugar. Although the CGM would 
make it easier for the enrollee to see impact on blood glucose of various foods, criteria for CGM coverage are 
not met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the FreeStyle Libre kit 2 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre kit 2 sensor.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis test (81001) provided on December 21, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that please reprocess and pay the Medicare 
allowable. Please see the claim and medical records attached. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the urinalysis test (81001) provided on December 
21, 2022, by an out-of-network (OON) provider.