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

 
We decided that the Plan does not have to pre-approve a Go-Go Sport power operated vehicle (POV) (power 
scooter). 
 You asked the Plan to pre-approve Go-Go Sport power scooter. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. You are requesting a specific brand  Go-Go Sport  that is not 
preferred by the Plan. No rationale has been given as to why this specific brand is needed to meet the enrollees 
medical needs compared to an equivalent power operated vehicle from one of the Plans preferred brands. 
Therefore, we decided that the Plan does not have to pre-approve a Go-Go Sport power operated vehicle (POV) 
(power scooter).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a home ventilator. You say that you need the CPAP in order to seep. The 
Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a home ventilator to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99496 rendered on February 6, 2023. 
 
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 validity and accuracy of the claim cannot be verified. 
 
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 99496 is "Transitional care management services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge High level of medical decision making during the service period 
Face-to-face visit, within 7 calendar days of discharge." 
 
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 history of the patient is 
unknown, and it is unclear if the visit is a true transitional care evaluation and management service. 
Transitional care management requires an interactive contact with the patient or caregiver, as appropriate, 
within two business days of discharge. The contract may be direct (face-to-face), telephonic, or by electronic 
means. For CPT 99496, the face-to-face visit must occur within 7 calendar days of the date of discharge and 
there must be a high level of medical decision making. This information could not be verified therefore medical 
records do not support the code. 
 
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 99496 rendered on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
January 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
incisional biopsy of oral tissue-soft (D7286) provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a Trilogy home ventilator. 
 
You asked the Plan to pre-approve the Trilogy home ventilator. You say that  the submitted documentation 
provides the medical necessity of the ventilator. The Plan denied your request. The Plan says the ventilator is 
not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 Trilogy home ventilator. Our 
reviewer says that the ventilator is not medically necessary. Our physician reviewer found the enrollee was 
admitted with a presumptive COPD exacerbation and had chronic respiratory failure. Symptoms improved in 
the hospital with BiPAP therapy and documentation does not support failure of BiPAP. Home ventilation is not 
indicated at this time per the documentation and data provided. 
 
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 Trilogy home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve  a Trilogy home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensor. You say that the enrollee has tried and failed 
the Accu-Chek smart view.  The Plan denied your request. The Plan says  Medicare only covers continuous 
glucose monitors (CGMs) for individuals who are on insulin at least once daily or have a history of problems 
with low blood sugar (hypoglycemia). 
 
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 3 sensor. Our 
reviewer says that the Freestyle Libre 3 sensor is not medically necessary. Our physician reviewer found the 
coverage criteria for CGM require low blood glucose sugar or insulin use. The enrollee is on Glipizide which 
can cause low blood glucose sugar but we are not told they are having any lows. Although the CGM would 
make it easier for the enrollee to monitor blood glucose sugar and might help their A1C, they do not meet 
coverage for CGM 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 3 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Feraheme. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have iron deficiency anemia. The documentation does not support that you have tried and failed 
Infed (iron dextran) and Venofer (iron sucrose). The documentation does not support that Infed (iron dextran) 
and Venofer (iron sucrose) would likely be less effective and/or likely have adverse effects. Therefore, the you 
do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 17, 
2021, through September 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not payable as the 
claim was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until December 19, 2022. This means that more 
than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided 
that the Plan does not have to pay for the acute inpatient hospital care provided from August 17, 2021, through 
September 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says that the step therapy requirements have not been met.  
 
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 Prolia. Our reviewer says that found 
Prolia is not medically necessary. Our physician reviewer found there is no evidence that the enrollee has tried 
and not responded to the other forms of medication. Also, there is no documentation as to why the other forms 
of medication would not be expected to be safe and effective for the enrollee. Also, there is no evidence that 
the enrollee has been taking basic supplements such as vitamins and calcium. Therefore, the requested use of 
Prolia is not shown to be currently 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was called and determined that your blood sugar was low. You also say that they gave you a shot 
and stated that you did not need to go to the hospital. The Plan denied your request. The Plan says these 
services are not a covered 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 July 30, 2022. 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 response and treatment with no 
transport provided on July 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the Intracept procedure at L2, L3, and L4. 
 
You asked the Plan to pre-approve  the Intracept procedure at L2, L3, and L4. You say that the enrollee needs 
the surgery is needed for their chronic back pain. You say the enrollee has tried and failed other treatments.  
The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. The Plan says 
no specific studies have been done to identify that the basivertebral nerve is the cause of the enrollee's pain.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure at L2, L3, and 
L4. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic 
changes without facet degenerative joint disease or stenosis. This means that the cause of back pain is not clear.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure at L2, L3, and L4 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  the Intracept procedure at L2, L3, and L4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the milrinone lactate (J2260) and the infusion supplies 
(A4221, A4222) provided from August 25, 2022, to September 1, 2022.  
 
 
You asked the Plan to pay for the milrinone lactate and the infusion supplies. You say that you are appealing 
the denial with supporting documentation. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
The record does not contain a valid proof of delivery. Therefore, we decided that the Plan does not have to pay 
for the milrinone lactate (J2260) and the infusion supplies (A4221, A4222) provided from August 25, 2022, to 
September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
February 7, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the services provided in this case.  
  
 
 
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97811) provided on February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
December 15, 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 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 provider reported the codes 
with modifier XU for unusual and non-overlapping services to bypass the edit with CPT 87801. However, the 
laboratory report does not contain documentation to support the rationale of using this code. Therefore, the 
codes and modifier cannot be verified. 
 
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 codes 87481, 87653, and 87798 rendered on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4197, B4220, and B4224 rendered from 
March 28, 2023, to April 1, 2023. 
 
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 denied codes remain 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) B4197: 
 
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix 
 
HCPCS B4220: 
 
Parenteral nutrition supply kit; premix, per day 
 
HCPCS B4224: 
 
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 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 fully 
support the use of these procedure codes. There needs to be documentation of the provider's orders for these 
specific does. The submitted documentation does not show the active order from the provider. The codes 
cannot be verified. 
 
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 codes B4197, B4220, and B4224 rendered from March 28, 2023, to April 1, 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 you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the records received don't show that the inpatient rehabilitation facility (IRF) services you are requesting 
meet the requirements for approval. 
 
 
 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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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.