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

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and specialty care transport 
(SCT) (A0434) provided on December 9, 2022. 
 
You asked the Plan to pay for the ground mileage and SCT. You say that this transport was medically 
necessary for the patient to receive the care they needed that was unavailable at the sending facility. The Plan 
denied your request. The Plan says the information provided at the time of the appeal does not support criteria 
for ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 
 
 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 ground mileage and SCT. Our reviewer 
says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record 
indicates that the patient was transported to another facility for a higher level of care. The record provided is 
insufficient to establish the medical necessity of the requested service. Our reviewer found that the record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. Our physician reviewer also found that the requested service cannot be 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 the ground mileage and SCT have not been met. Therefore, we decided that the 
Plan does not have to pay for the ground mileage (A0425) and specialty care transport (SCT) (A0434) provided 
on December 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport that you received 
on April 27, 2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the services were 
medically necessary. The Plan denied your request. The Plan says these services are not a covered benefit 
because ambulance is a transport benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services without transport that you 
received on April 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that  the enrollee is a fall risk, is very weak and does not 
have anyone to care for them at home. You say the enrollee has not had any physical and occupational therapy. 
The Plan denied your request. The Plan says the SNF services requested do not meet the requirements for 
approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image 
guidance, includes placement of intra-articular implant(s) (0775T). 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant(s). You say that this is medically necessary. The Plan denied your request. 
The Plan says a review of the current medical literature does not consider this service to be standard medical 
treatment for the enrollee's condition. 
 
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 arthrodesis, sacroiliac joint, 
percutaneous, with image guidance, includes placement of intra-articular implant(s). Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
sacroiliitis pathology. The radiographic images demonstrate degenerative joint disease; however, the magnetic 
resonance imaging did not corroborate this. Multiple other plausible pain generators including at the 
lumbosacral spine are evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale 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 arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes 
placement of intra-articular implant(s) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-
articular implant(s) (0775T).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation to medical appointments as the enrollee cannot drive. The Plan denied your request. The Plan 
says the enrollee has utilized the maximum number of transportation trips allowed per 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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition supplies (B4193, B4220, B4224) 
provided from May 6, 2023, to May 9, 2023. 
 
You asked the Plan to pay for parenteral nutrition supplies. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the Plan already paid these codes and the records do not 
support additional units. 
 
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 B4193 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements, and vitamin, including preparation, any 
strength, 10 to 51 grams of protein  premix. The CPT Code Manual definition of code B4220 is parenteral 
nutrition supply kit; premix, per day. The CPT Code Manual definition of code B4224 is parenteral nutrition administration kit, per day. 
 
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 parenteral nutrition supplies. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found the Plan paid a claim for these codes on June 1, 
2023 and the documentation does not support additional units of these codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parenteral nutrition supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for parenteral nutrition supplies (B4193, B4220, B4224) provided from May 6, 2023, 
to May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on June 06, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were charged for a 
service/CPT code that did not happen. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for in-network physician/practitioner services. 
 
You have been asked to pay a $5 copayment for the arthrocentesis. This item/service falls within the in-
network physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The records show you were charged for CPT code 26010, not CPT code 
26011. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis 
provided on June 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item was 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 the pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D4263), and a guided tissue 
regeneration (D4266) provided on May 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered 100%. The Plan denied 
your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service May 11, 2023. Therefore, we 
decided that the Plan does not have to pay for a bone replacement graft (D4263), and a guided tissue 
regeneration (D4266) provided on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 and T12 kyphoplasty (22513, 22515). 
 
You asked the Plan to pre-approve T10 and T12 kyphoplasty. You say that this is medically necessary. The 
Plan denied your request. The Plan says medical necessity coverage criteria are not met. 
 
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 T10 and T12 kyphoplasty. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss at both levels, kyphotic deformity, or a severe impact 
on daily activities. Moreover, there is magnetic resonance imaging corroboration of retropulsion and other 
plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T10 and T12 kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve T10 and T12 kyphoplasty (22513, 22515).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 18, 2022, to 
August 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the diagnoses billed. The Plan denied your request. The Plan says the billed diagnoses 
of A41.9 Sepsis, unspecified organism and R65.20 Severe sepsis without septic shock are not supported by the 
medical record. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnoses of A41.9 Sepsis, unspecified organism 
and R65.20 Severe sepsis without septic shock. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the billed diagnoses of  
A41.9 Sepsis, unspecified organism and R65.20 Severe sepsis without septic shock are not supported by the 
medical record. Our physician reviewer found the enrollee is a 75-year-old female who presented to the 
hospital for surgery with elevated lipase, gallstones, and thickened gallbladder wall. She reported no abdominal 
pain at the time. She was diagnosed with cholecystitis. The diagnoses A41.9, Sepsis, unspecified organism and 
R65.20, Severe sepsis without septic shock are each not supported by the medical record. Workup revealed the 
patient was alert and oriented, she had normal platelets, normal blood pressure, no oliguria, and no hypoxia. 
Although the bilirubin was elevated, this was directly related to the gall bladder disease, and an elevated 
creatinine was directly related to acute kidney injury related to dehydration, not organ failure related to a 
systemic dysregulation from a systemic infection. The Sepsis 3 criteria were not met, and there was no 
evidence of shock.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 18, 2022, to August 23, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 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 April 3, 2023, billed with 
codes U0005, 87798, 87486, 87581, U0003, 87634, 87498, 87502, and 87503. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel 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 
April 3, 2023, billed with codes U0005, 87798, 87486, 87581, U0003, 87634, 87498, 87502, and 87503.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure for 
musculoskeletal procedures (20985). 
 
You asked the Plan to pre-approve a computer-assisted surgical navigational procedure for musculoskeletal 
procedures. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical 
value and effectiveness of MAKOplasty for robotic assistance in the setting of total joint arthroplasty has 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 computer-assisted surgical 
navigational procedure for musculoskeletal procedures. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there are no 
large volume, long-term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of 
functional improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in 
total shoulder arthroplasty. 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 a computer-assisted surgical navigational procedure for musculoskeletal 
procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer-
assisted surgical navigational procedure for musculoskeletal procedures (20985).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on May 15, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required (D2950), and crown - 
porcelain/ceramic (D2740). You say that you and the provider were told by the plan they were in-network and 
now the claims are denying. The Plan denied your request. The Plan says core buildup is not a covered expense 
under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on May 15, 2023.