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

 
We decided that the Plan has to pay for comprehensive series of radiographic images (D0210) provided on 
May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that there is no evidence that this was previously 
provided. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for comprehensive series of radiographic images 
(D0210) provided on May 16, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 skilled nursing visits.   
 You asked the Plan to pre-approve home health services. You say that the enrollee has dementia and is 
currently in a memory care facility. Consequently, the enrollee is not able to change the dressing independently 
and family members have not been educated on dressing changes. You also say the frequency of dressing 
changes by home health care is needed to prevent further damage and possible infection of the enrollee's heel.  
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services to improve the enrollees condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbation of chronic medical problems or hospitalizations. The requested home 
health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
procedure codes 93228-59 and 93229. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 93228-59 and 93229 is external mobile cardiovascular 
telemetry with electrocardiographic (ECG) recording, concurrent computerized real time data analysis and 
greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient 
selected events transmitted to a remote attended, and external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days, review and interpretation with report by 
a physician or other qualified health care profession. Technical support for connection and patient instructions 
for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a 
physician or other qualified health care professional surveillance center for up to 30 days; review and 
interpretation with report by a physician or other qualified health care professional. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the report does not include 
documentation of connection and patient instruction, a physician order communicating physician's direction for 
ancillary services and required diagnostic tests, as well as physician order for service provided, and therefore 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with procedure codes 
93228-59 and 93229.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single-photon emission computed tomography (SPECT) 
testing. 
 
You asked the Plan to pre-approve SPECT testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the record does not show that the enrollee is experiencing new, 
recurrent, or worsening symptoms related to the heart. 
 
The Plan follows Medicare rules. Medicare rules state that SPECT testing may be covered for certain 
indications. 
 
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 SPECT testing. Our reviewer says that 
the enrollee does not meet criteria for this testing. Our physician reviewer found the documentation does not 
suggest that the enrollee is having any symptoms that would be attributable to a cardiac condition such as 
myocardial ischemia. The provider notes mention an abnormal electrocardiogram (ECG), but the specific 
findings are not noted, nor is the ECG interpretation included. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve single-photon emission computed tomography (SPECT) testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on June 13, 
2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are asking for a 
reconsideration of the cost share applied. 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 $40 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $40 copayment for physical therapy. This item/service falls within the outpatient 
rehabilitation 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. You have been asked to pay a total of $414.02 for physical therapy services from June 13, 
2020 to June 29, 2023. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided on June 13, 2023, to June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 rendered on December 20, 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 claim should be resubmitted with medical/operative notes. 
 
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 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 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 enrollee was treated on 
12/20/22 with advance care planning for deep vein thrombosis and embolism. However, the provided records 
described the enrollee's care at the skilled nursing facility was already reimbursed for this stay including the 
advance care planning which would not be payable separately in this case. There was no indication that this 
assessment was independent of the covered and paid stay. Therefore, the documentation does not support CPT 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99497 rendered on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62322 billed for date of service May 9, 2023. 
 You asked the Plan to pay for procedure code 62322. You say that this procedure was performed for post-
operative pain management. The Plan denied your request. The Plan says payment for code 62322 is bundled 
into payment for code 00800. 
 
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 62322 
is a column II code to column I code 00800. This claim 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 62322 billed for date of service 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 the medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for metabolic encephalopathy and urinary tract infection. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
request for inpatient rehabilitation facility services do not 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 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 
was admitted for transcathether aortic valve replacement. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care to 
optimize recovery. The Plan denied your request. The Plan says the enrollee's needs can be managed at the 
current facility until they are more stable for transfer to another level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is still somewhat unstable and requires only short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
The enrollee does not require services at the LTACH that are not already available at the current facility.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Nalu peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that this will positively affect the 
enrollee's life. The Plan denied your request. The Plan says there is insufficient evidence to support use of a 
peripheral nerve stimulator. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental for shoulder 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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of a Nalu peripheral nerve stimulator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services to improve the enrollees condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbation of chronic medical problems or hospitalizations. The requested home 
health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scan of lower extremity arteries. 
 
You asked the Plan to pre-approve duplex scan of lower extremity arteries. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that duplex scanning of the lower extremity arteries 
performed to establish the level and/or degree of arterial occlusive disease, will be considered medically 
necessary if a) significant signs and/or symptoms indicate a high likelihood of limb ischemia, and b) the patient 
is a candidate for invasive therapeutic procedures. 
 
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 duplex scan of lower extremity arteries. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has atherosclerosis of native arteries of extremities. The record provided does not 
establish the existence of an enumerated condition for which coverage is available for the requested service. 
The elements of the coverage criteria are not satisfied. The requested service is not 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 duplex scan of lower extremity arteries have not been met. Therefore, we 
decided that the Plan does not have to pre-approve duplex scan of lower extremity arteries.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator (K0108). 
 
You asked the Plan to pre-approve the external upper limb tremor stimulator. You say that this device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 external upper limb tremor 
stimulator. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the literature that this device is 
effective for the patient's tremor. 
 
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 external upper limb tremor stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external upper limb tremor stimulator (K0108).