Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of an infusion pump (62361, 62362). 
 
You asked the Plan to pre-approve implantation of an infusion pump. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted infusion pumps are 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 implantation of an infusion pump. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets 
coverage criteria detailed in the NCD for the infusion pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of an infusion pump have been met. Therefore, we decided that the 
Plan has to pre-approve implantation of an infusion pump (62361, 62362).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that you are very frustrated and are in alot of pain. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the guidelines require 80% pain relief from each set of diagnostic blocks. This was not achieved. 
Therefore, the request is deemed not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar facet joint radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided January 
10, 2023. 
 You asked the Plan to pay for a pneumatic compression device. You say that you feel that you have met the 
policy guidelines for medical necessity. The Plan denied your request. The Plan says pneumatic compression 
device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0676) provided January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure (37220). 
 
You asked the Plan to pre-approve a revascularization procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that vascular stents are used to enhance primary patency 
in arteries and veins, usually at the site of stenotic or occlusive lesions. 
 
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 a revascularization procedure a revascularization 
procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
records in this case do not support that a thorough medical evaluation and management of symptoms and a 
preoperative risk stratification have been completed to meet LCD criteria for the procedure. 
 
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 revascularization procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a revascularization procedure (37220).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for February 5, 2023. 
 
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 the billed diagnosis codes are not valid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with two diagnosis codes 
that exclude each other. 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 the emergency room 
(ER) services billed with code 99285 for February 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 16, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are seeking retro authorization. The Plan denied 
your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 16, 2023, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided February 
1, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that as the enrollee's provider, you feel 
that you met the policy guidelines for medical necessity. The Plan denied your request. The Plan says the 
equipment was prescribed by the doctor and was issued to the enrollee for use during their surgery. 
 
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) provided February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454 x6). 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 genicular nerve blocks. 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 an experimental therapy at this time. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks (64454 x6).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided August 
17, 2022, to September 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial. You 
believe these services were medically necessary. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) provided August 17, 2022, to 
September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services billed with an inpatient place of service on 
February 16, 2023. 
 
You asked the Plan to pay for surgical services billed with an inpatient place of service. You say that the 
records do not support an inpatient level of care. The Plan denied your request. The Plan says these services 
were billed correctly as inpatient services. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 surgical services billed with an inpatient 
place of service. Our reviewer says that the documentation does not support that the criteria for inpatient 
payment are met in this case. Our physician reviewer found the submitted documentation does not support an 
inpatient level of care. The procedure performed is not on the inpatient only list and no clinical documentation 
was submitted detailing severity of illness or intensity of service for inpatient care, rather than observation. The 
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical services billed with an inpatient place of service have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical services billed with an inpatient place of 
service on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bitewing x-rays provided on February 15, 2023. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you thought your benefit limits and annual 
maximum would start over. The Plan denied your request. The Plan says that bitewing x-rays are only covered 
once every 12 months. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan says your benefit has been exhausted. However, the Plan 
did not submit documentation showing when bitewing x-rays were last received or that bitewing x-rays were 
paid for within the last 12 months. This means that the Plan did not substantiate their decision to deny payment 
for the x-rays. Therefore, we decided that the Plan has to pay for the bitewing x-rays provided on February 15, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of premalignant lesions (17000, 17003) 
provided on April 25, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says a primary Evidence of Benefits (EOB) has not been received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the 
primary EOB from the provider. As the secondary insurer, the Plan cannot be held responsible for the surgical 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the destruction of premalignant lesions (17000, 17003) provided on April 25, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for stent placement on October 25, 2022. 
 
You asked the Plan to waive the coinsurance for stent placement. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a 20% coinsurance for outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The Plan says you must pay a 20% coinsurance for stent placement. Based on the Plan contract, however, you 
cannot be asked to pay more than a 20% coinsurance for stent placement. Therefore, we decided that the Plan 
has to waive the coinsurance for stent placement on October 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on  
November 17, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only 
for diabetes and renal disease 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on November 17, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the definitive drug testing as billed. We decided that the Plan does not 
have to pay for the presumptive testing.  
 
You asked the Plan to pay for the presumptive drug testing (80307) and definitive drug testing of 15-22 drug 
classes (G0482) provided on January 24, 2023. You say that these services should be paid. The Plan says that 
the presumptive testing cannot be paid as it was redundant to the point-of-care testing done by the physician. In 
addition, only 11 drug classes were tested meaning that code G0482 is not supported.  
 
We decided that the Plan has to pay for the definitive drug testing as 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. 
 
Code G0482 refers to definitive drug testing of 15-22 drug classes. Review of the lab report shows that 16 
classes were tested. As such, the use of code G0482 is supported. Therefore, we decided that the Plan has to 
pay for the definitive drug testing as billed.  
 
We also decided that the Plan does not have to pay for the presumptive testing. 
 
The Plan follows Medicare rules. Medicare rules say that payment can only be made for one presumptive drug 
test per patient per date of service regardless of the provider that bills for the testing.  
 
In this case, the physician provided and was paid for presumptive drug testing performed in the office. A 
second presumptive drug test from the reference laboratory cannot be paid. Therefore, we decided that the Plan 
does not have to pay for the presumptive testing. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 16, 2021. 
 
You asked the Plan to pay for the physician service. You say that you made every effort to submit this claim on 
time. You also say that an exception should be made. The Plan denied your request. The Plan says the claim 
was not filed timely. 
 
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 the physician service was not filed until January 27, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on September 16, 2021.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says services requested can be provided safely in alternative 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.