Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 97140, 97161, 97530, G0283 rendered from March 
28, 2023, to April 11, 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 that there was no plan of care, so the GP modifier is 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. 
 
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 supported by the medical records. Our reviewer found the plan has denied these codes due to a 
plan of care not being documented. However, a treatment plan with diagnoses and measures of treatment with 
long term goals is documented in the records. Therefore, the codes are supported in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 97140, 97161, 97530, G0283 rendered from March 28, 2023, to April 11, 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 pre-approve sacral nerve stimulation. 
 You asked the Plan to pre-approve the requested services. You say that Botox and medications have not 
worked. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that the requested sacral nerve stimulation is not indicated for the enrollee's condition. 
Cystoscopy shows anterior prostate obstruction. A hemoglobin A1c was not provided. Given significant 
glycosuria and urine ketones, the enrollee likely has polyuria, advanced peripheral nerve involvement (diabetic 
cystopathy), and secondary voiding manifestations. There is also no record of behavioral/pelvic floor therapy. 
As such, the enrollee does not meet guideline requirements. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacral nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 rendered on August 30, 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 Current Procedural Terminology (CPT) code 99215-25 (1 unit) remains 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 code 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter." 
 
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 
support the use of an evaluation and management code (CPT 99215) for this date of service. The records only 
support that an injection was performed, but no additional evaluation and management was performed that 
warranted the use of CPT 99215. 
 
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 99215 rendered on August 30, 2022.
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 exceeds criteria for an 
appropriate LTACH admission. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
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 there is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital 
until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level 
of care for any ongoing long term care needs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (continued use). 
 
You asked the Plan to pre-approve a home ventilator (continued use). You say that the requested home 
ventilator is medically necessary. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS). 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 a home ventilator (continued use). Our 
reviewer says that the home ventilator is not medically necessary. Our physician reviewer found this enrollee 
has COPD and idiopathic pulmonary fibrosis. The enrollee has had multiple hospitalizations in the recent 
months. An arterial blood gas done on March 9, 2023, during hospitalization for a COPD exacerbation, showed 
a (potential of hydrogen) pH of 7.41 and a partial pressure of carbon dioxide (PaCO2) of 36, which is 
normal. Pulmonary function tests show a forced expiratory volume (FEV1) of 68% of predicted, which is not 
severely enough impaired to expect chronic (carbon dioxide) CO2 retention. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. Therefore, this enrollee does not meet need criteria for a nocturnal 
respiratory assist device. In addition, Medicare does not cover a home ventilator when used at settings that can 
be provided with BiPAP.  
 
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 home ventilator (continued use) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator (continued use).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) for teeth numbers 1 
and 4, and a retainer crown - porcelain/ceramic (D6740) for teeth numbers 2, 3. 
 
You asked the Plan to pre-approve pontic - porcelain/ceramic (D6245) for teeth numbers 1 and 4, and a retainer 
crown - porcelain/ceramic (D6740) for teeth numbers 2, 3. You say that you do not understand the Plan's 
decision since it is a service that the Plan offers. You also say that this is the first time you are requesting the 
service.  The Plan denied your request. The Plan says the criteria is not met because the service is more than the 
patient clinical need. 
 
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 pontic - 
porcelain/ceramic (D6245) for teeth numbers 1 and 4, and a retainer crown - porcelain/ceramic (D6740) for 
teeth numbers 2, 3 when the services are medically necessary and reasonable.   
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 pontic - porcelain/ceramic (D6245) for 
teeth numbers 1 and 4, and a retainer crown - porcelain/ceramic (D6740) for teeth numbers 2, 3. Our reviewer 
says that the requested treatment is not medically necessary. Our physician reviewer found the request for 
retainer crowns - porcelain/ceramic (D6740) are not possible since tooth number 2 is missing. Our physician 
reviewer also found the request for pontics - porcelain/ceramic (D6245) are not reasonable since there is no 
need to replace tooth number 1, and tooth number 5 is present. 
 
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 pontic - porcelain/ceramic (D6245) for teeth numbers 1 and 4, and a retainer 
crown - porcelain/ceramic (D6740) for teeth numbers 2, 3 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) for teeth numbers 1 and 4, and a retainer 
crown - porcelain/ceramic (D6740) for teeth numbers 2, 3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alarm device (A9280). 
 
You asked the Plan to pre-approve an alarm device. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alarm device (A9280).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that it is medically necessary. The 
Plan denied your request. The Plan says it 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no plausible reason that proton therapy would be more beneficial 
than standard therapy for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power standing system (E2301), a joystick 
touchscreen (K0108), back caners (K0108), and arm pads (K0108). 
 
You asked the Plan to pre-approve the joystick touchscreen, arm pads, power standing system, and back canes. 
You say that the items are medically necessary. The Plan denied your request. The Plan says the joystick 
touchscreen and arm pads are unbundled and cannot be covered. The power standing system and back canes do 
not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power standing system (E2301), a joystick touchscreen 
(K0108), back caners (K0108), and arm pads (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on March 7, 2023, to 
March 9, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on March 7, 2023, to March 9, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no evidence that this enrollee has tried the basic 
pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental appliances (E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has completed various 
conservative therapies. The Plan denied your request. The Plan says the enrollee has not failed alternative 
treatments.  
 
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 requested services. Our physician 
reviewer found that there is no sacroiliac (SI) joint instability, fracture, or lesion. SI joint fusion for 
degenerative back pain is experimental. Therefore, the requested service is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit provided by a chiropractor on June 7, 
2023.  
 
You asked the Plan to pre-approve an office visit. You say that you saw the chiropractor for your back pain. 
The Plan denied your request. The Plan says that an office visit provided by a chiropractor is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve an office visit provided by a chiropractor on June 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior cervical fusion for C5-6 and C6-7 (22551, 
22845, 22853). 
 
You asked the Plan to pre-approve anterior cervical fusion for C5-6 and C6-7. 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 anterior cervical fusion for C5-6 and 
C6-7. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found imaging does not show severe stenosis or instability. 
There is no correlation with a physical exam.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anterior cervical fusion for C5-6 and C6-7 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve anterior cervical fusion for C5-6 and C6-7 (22551, 22845, 
22853).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the enrollee does not have the ability to receive this 
medication through buy-and-bill. The Plan denied your request. The Plan says this drug is not covered by 
Medicare Part B when dispensed directly by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Supartz.  
 
Benefits for Supartz may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you have not had a top denture for the past 
3 years. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete upper denture (D5110) on January 17, 2020; therefore, your benefit for the 
complete upper denture (D5110) was exhausted on the date of service of January 17, 2020. The records also 
shows that the Plan paid for a partial lower denture (D5214) on June 2, 2020; therefore, your benefit for the 
partial lower denture (D5214) was exhausted on the date of service of June 2, 2020. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
procedure has not been proven to be helpful for the treatment of the enrollee's problem.  
 
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 requested services. Our physician 
reviewer found that bone marrow aspiration during approved spinal surgery was requested. bone marrow 
aspirate is experimental. More research is needed to show its safety and efficacy. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.