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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676, E0673, E0656). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676, E0673, E0656).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you had open heart surgery and you need 
to go to the dentist office to get your teeth. You also say that the only dentist office that was available to 
provide the service is far away. The Plan denied your request. The Plan says your benefit plan does not cover 
more than 30 one-way trips per plan year. 
 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 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve 12 
additional routine transportation trips. 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 12 additional routine transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676, E0673, E0656) 
provided on January 13, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says a PCD is not covered when used for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676, E0673, E0656) provided on January 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that the enrollee is running out of medication. The Plan 
denied your request. The Plan says that self-administered drugs do not fall under Medicare 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 Actemra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction erupted tooth or exposed root (D7140) and 
surgical removal of erupted tooth (D7210). 
 
You asked the Plan to pre-approve extraction erupted tooth or exposed root and surgical removal of erupted 
tooth . You say that this is medically necessary. The Plan denied your request. The Plan says you are not 
enrollee in the dental plan so this is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extraction erupted 
tooth or exposed root (D7140) and surgical removal of erupted tooth (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service May 17, 
2023. 
 You asked the Plan to pay for procedure code 99214. You say that medical records were provided. The Plan 
denied your request. The Plan says payment for code 99214 is bundled into payment for code 94010. 
 
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 have confirmed that code 99214 is a column II code to column I code 94010. Code 99214 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 
billed for date of service May 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the Plan failed to comply with timelines. The 
Plan denied your request. The Plan says the billed code is not substantiated by the documentation. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with a headache, determined to most likely be caused by a new medication. 
The records do not show that a high level of medical decision making was provided. 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 99285 billed for date of service May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental when used as bone graft material. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), a limited oral 
evaluation (D0140), the intraoral radiographic image (D0220), a cleaning (D1110), a resin-based composite 
(D2392), a crown (D2740), and core buildup (D2950), and to pay for the intraoral complete series of 
radiographic images (D0210), the intraoral radiographic images (D0220 and D0230), bitewings (D0274), and a 
protective restoration (D2940) provided by out-of-network providers on November 12, 2022, December 2, 
2022, January 18, 2023, and March 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the provider changed to 
an out-of-network provider. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The proper cost share was applied. The intraoral complete series of radiographic images and the 
protective restoration are not covered by the Plan. Your benefit for the intraoral radiographic images and 
bitewings 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. 
 
You have been asked to pay a 50% coinsurance and the difference between the out-of-network providers 
charges and the Plans payment for the periodic oral evaluation, a limited oral evaluations, the intraoral 
radiographic image, the cleaning, a resin-based composite, crowns, and core buildup. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The record shows the Plan paid for the 
intraoral radiographic image (D0220) on December 12, 2022; therefore, your benefit for the intraoral 
radiographic image and bitewings was exhausted on date of service of December 12, 2022. The intraoral 
complete series of radiographic images and the protective restoration are not covered under the Plans dental 
benefit. Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), a 
limited oral evaluation (D0140), the intraoral radiographic image (D0220), a cleaning (D1110), a resin-based 
composite (D2392), a crown (D2740), and core buildup (D2950), and to pay for the intraoral complete series of 
radiographic images (D0210), the intraoral radiographic images (D0220 and D0230), bitewings (D0274), and a 
protective restoration (D2940) provided by out-of-network providers on November 12, 2022, December 2, 
2022, January 18, 2023, and March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure machine with stethoscope. 
 
You asked the Plan to pre-approve a blood pressure machine with stethoscope. You say that the item is 
medically necessary. The Plan denied your request. The Plan says medical records do not show the beneficiary 
does not have suspected white coat hypertension nor suspected masked hypertension. Furthermore, there is no 
evidence the member is currently on home dialysis. The records do not show a standard blood pressure monitor 
would meet the member's needs.  
 
The Plan must follow Medicare rules. Medicare rules say that Ambulatory Blood Pressure Monitoring (ABPM) 
is reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries under the following circumstances:  
1. For beneficiaries with suspected white coat hypertension.  
2. For beneficiaries with suspected masked hypertension. 
home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are considered home dialysis 
supplies. These items are only covered for patients on home dialysis, and they are not payable to Durable 
Medical Equipment suppliers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a blood pressure machine with stethoscope have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a blood pressure machine with stethoscope.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral appliance (E0486) provided on January 10, 2023. 
 
You asked the Plan to pay for the oral appliance. You say that this device was medically necessary. The Plan 
denied your request. The Plan says coverage rules were not met. 
 
The Plan follows Medicare rules. Medicare rules say that an oral appliance for obstructive sleep apnea is 
covered when the records show the beneficiary is not able to tolerate a positive airway pressure (PAP) device; 
or, the treating practitioner determines that the use of a PAP device is contraindicated. 
 
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 oral appliance. Our reviewer says that 
this device was not medically necessary. Our physician reviewer found the records do not show intolerance to a 
PAP device. The records from sleep medicine documented that the enrollee is tolerating the PAP treatment 
well, and quality of sleep had improved. 
 
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 oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pay for an oral appliance (E0486) provided on January 10, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency services (99285) and a simple repair of superficial wounds 
of scalp, neck, axillae, external genitalia, trunk and/or extremities (12002) provided on March 12, 2023. 
 
You asked the Plan to pay for emergency services. You say that you are requesting reconsideration because the 
services provided are supported with medical documentation. The Plan denied your request. The Plan says that 
coding level 99285 was not supported. 
 
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 emergency services. Our reviewer says that the service meets 
criteria for payment on this claim. Our reviewer found code 99285 is supported by the documentation. The 
complexity of the problems addressed was high, a head injury and the enrollee is on warfarin. A computed 
tomography (CT) of the head was performed to rule out hemorrhage. The data was also high, 3+ tests and 1 
interpretation. The risk was moderate. This meets criteria in 2 of 3 categories to report 99285. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency services have been met. Therefore, we decided that the Plan has to 
pay for emergency services (99285) and a simple repair of superficial wounds of scalp, neck, axillae, external 
genitalia, trunk and/or extremities (12002) provided on March 12, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole. 
 
You asked the Plan to pre-approve the medication. You say that you have been using this medication for your 
stomach problems and to help you eat and you would like to continue to take it. The Plan denied your request. 
The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 Esomeprazole.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and physical therapy services provided by 
a chiropractor on March 27, 2023, to May 9, 2023. 
 
You asked the Plan to pre-approve the office visit and physical therapy services. You say that you need 
adjustments because your vertebrae are misaligned and is impinging on your artery. The Plan denied your 
request. The Plan says that services other than manipulations are not covered because they are excluded by the 
Plan when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve an office visit and physical therapy services provided by a chiropractor 
on March 27, 2023, to May 9, 2023.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee can receive care safely in an alternate setting.  
 
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 nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2023, billed 
with codes 87631, 87651, 87653, 87798, and 87637. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were deemed medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a respiratory pathogen panel was provided. We looked at the file and Medicare rules. This 
panel testing was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on February 23, 2023, billed with codes 87631, 87651, 
87653, 87798, and 87637.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. You say that you have been on this medication for 36 years and 
have never taken a generic brand. You say that you do not feel after this long period of time your body would 
adjust to the generic brand. The Plan denied your request. The Plan says that self-administered drugs do not fall 
under Medicare 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 Synthroid.  
 
Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2260 billed for September 19, 2022, to 
September 28, 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 procedure code J2260 is 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 J2260 is injection, milrinone lactate, 5 mg. 
 
We find that CPT code J2260 is not supported in the medical record. Specifically, the records do not support 
the units billed. 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 pay for procedure code J2260 billed for 
September 19, 2022, to September 28, 2022.