Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes M62.830 and 
M79.10. Diagnosis code M62.830 has an Excludes1 note and is not payable when billed with diagnosis code 
M79.10. 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 the services provided on December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88312, 88361, 88305) provided on 
October 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and request 
reconsideration of payment on the claim. The Plan denied your request. The Plan says this service is not a 
covered benefit with Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file and Medicare rules. The records show that this service is experimental and investigational 
and not a covered benefit. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(88312, 88361, 88305) provided on October 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided on December 24, 
2022. 
 
You asked the Plan to pay for air ambulance. You say that the records support the need for this service. The 
Plan denied your request. The Plan says there was no clear barrier to transportation to the closest appropriate 
facility or use of ground transportation. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance. Our reviewer says that this 
transportation does not meet criteria for payment. Our physician reviewer found the enrollee was being treated 
at a small hospital for COVID-19 and the decision was made to transfer the enrollee to a larger hospital for 
ongoing care. While a transfer itself was medically reasonable, it does not appear that the enrollee was 
transported to the closest appropriate facility. There is no documentation that closer facilities were unavailable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance transportation provided on December 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4215 and A4557 rendered on November 
18, 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 provider did not bill as required by Medicare coding regulations. 
 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: 
 
A4215: 
 
Needle, sterile, any size, each 
 
A4557: 
 
Lead wires, (e.g., apnea monitor), per pair 
 
We find that these codes are not supported in the medical record. Specifically, in terms of A4557, this code has 
a status indicator of P. This means that this code is always bundled into payment for other services. No separate 
payment can be made. 
 
In terms of A4215, this code has a Medically Unlikely Edit (MUE) value of 0. This means that no units of this 
code are appropriate to be billed.  
 
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 A4215 and A4557 rendered on 
November 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 15, 2022, billed 
with code 71271. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that claims for low-dose CT lung cancer screenings 
are denied if they are not reported with the listed diagnosis codes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis code Z12.2 
which is not a listed diagnosis code for this procedure. Therefore, we decided that the Plan does not have to pay 
for imaging services provided on December 15, 2022, billed with code 71271.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that you are 
the sole provider of the Lympha Press product line in the state of Arizona. The Plan denied your request. The 
Plan says there are network providers within a reasonable distance of the enrollee's location that can provide 
the necessary items.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 pneumatic compression device and 
related supplies. Our reviewer says that the requested items can be provided by an in-network provider. Our 
physician reviewer found that while the documentation supports the medical necessity of an advanced 
lymphedema pump, it does not support the need for a particular brand of device. There is adequate 
documentation of failure of efforts at compressive therapy to alleviate the enrollees symptoms and there is 
documentation of lymphedema extending onto the trunk. However, there is no documentation of unique 
features that would necessitate a particular brand of pump, and, in fact, the provider recommended an advanced 
lymphedema pump from another company. It is possible that efforts to obtain a particular brand of pump may 
be delaying the enrollee getting needed services. 
 
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 pneumatic compression device and related supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and related 
supplies to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle kit sensor.  
You asked the Plan to pre-approve a FreeStyle kit sensor. You say that you would like the enrollee to continue 
monitoring until they can get their glycohemoglobin (A1C) down below the diabetic range. The Plan denied 
your request. The Plan says a continuous glucose monitor is not covered under Medicare if the member is not 
on insulin or does not have documentation of history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle kit sensor have not been met.  Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle kit sensor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3.  
 You asked the Plan to pre-approve Gelsyn-3. You say that the medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
step therapy drugs.  
 
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 Gelsyn-3. Our reviewer says that the 
Gelsyn-3 is not medically necessary. Our physician reviewer found that the Plan requires a trial of drug 
Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. The 
enrollee has not tried and failed the required medications. The required drugs would not likely be less effective 
or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have had three falls recently and cannot safely 
return home. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 16, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services to 
help recover from losing your foot. The Plan denied your request. The Plan says that you do not meet the 
Medicare criteria for admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary for the enrollee. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary. 
 
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 receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
computed tomography (CT) for attenuation. 
 
You asked the Plan to pre-approve the PET scan with CT for attenuation. You say that the services are 
medically necessary. The Plan denied your request. The Plan says they need more information to show why the 
testing needs to be done.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET scan with CT for attenuation. 
Our reviewer says that the PET scan with CT for attenuation is not medically necessary. Our physician 
reviewer found the enrollee's most recent CT was February 18, 2022, and the PET/CT that followed on April 
14, 2022, was negative for malignancy; rather round atelectasis was the diagnosis. Since the most recent CT 
was February 18, 2022, it would be reasonable to have repeat CT to determine if the requested PET/CT is 
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 PET scan with CT for attenuation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
computed tomography (CT) for attenuation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgical procedure (38206) provided on April 13, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that the service is not covered. 
 
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. The Plan did provide a valid denial reason. Therefore, we decided that the Plan 
has to pay for the surgical procedure (38206) provided on April 13, 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 pre-approve a referral to an out-of-network provider for an office 
consultation.  
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate procedure code.  
 
The requested provider in this case is not a network provider with the Plan. We found no exception that would 
require the Plan to pre-approve these items/services. Furthermore, the services requested are an office 
consultation described by code 99244. This code has a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure code 99244 is not valid for Medicare purposes. Therefore, we decided that the Plan 
does not have to pre-approve a referral to an out-of-network provider for an office consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the tanks provided by the Plan only last 
about 2 hours and are too heavy. The Plan denied your request. The Plan says the Plan does not cover duplicate 
item. The Plan is currently providing the enrollee with the most appropriate equipment that meets the enrollee's 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable D-cylinder oxygen tanks. Specifically, a home oxygen concentrator, 
home fill oxygen system, and portable D-cylinder oxygen tanks was provided April 2, 2023. The portable D-
cylinder oxygen tanks serves the same purpose as the oxygen equipment. Therefore, we decided that the Plan 
does not have to pre-approve the Inogen portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent bridge for tooth numbers 21-28 (D6245 x 
2, D6740 x 6). 
 
You asked the Plan to pre-approve the dental services. You say that you have tried several times to use partial 
dentures but cannot adapt to them. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. The Plans criteria states when teeth are 
missing in both quadrants of the same arch, a benefit request for one or more fixed bridges in that arch will be 
limited to the benefit of a conventional tooth and soft tissue-based partial denture. 
 
 
  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 dental services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found that there are many missing 
teeth on both sides of the arch, the Plans provisions would limit reimbursement to the benefit of a partial 
denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a permanent bridge for tooth numbers 21-28 (D6245 x 2, D6740 x 6).