Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient or observation care, per day, for 
the evaluation and management of a patient (99222) provided on January 13, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  
 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
 
The enrollee initially ended Medicare Hospice benefits on January 9, 2023. The service in question was 
provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial 
hospital inpatient or observation care, per day, for the evaluation and management of a patient (99222) 
provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218), provided 
on March 8, 2023, through March 28, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218), provided on March 8, 2023, through 
March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the cataract surgery provided on May 15, 
2023. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that you were given incorrect cost 
sharing information by the Plan. 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. Your 
contract with the Plan says that there is a $350 deductible which applies to outpatient surgery. Your contract 
with the Plan also says that you must pay a $400 copayment after meeting the deductible for in-network 
outpatient surgery provided at an ambulatory surgical center. 
 You have been asked to pay $350 towards the deductible. The item or service you asked the Plan to waive the 
deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $350 deductible which applies to outpatient surgery. This cost 
sharing is a contractual obligation that had not been met at the time the cataract surgery was received on May 
15, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the cataract surgery 
provided on May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary because 
you have ongoing medical issues including diabetes and wound care. You also have physical restrictions with 
bending, twisting, and reaching which make it difficult to transport you to medical appointments. The Plan 
denied your request. The Plan says your needs can be met at an alternate level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is in fact complex and post-operatively the placement of the stimulator is 
delicate, requiring skilled instruction on adaptive behaviors. There is every reason to expect that the enrollee 
will participate in and benefit from services to include at minimum physical therapy, occupational therapy, 
physician oversight of polypharmacy, and case manager coordination of any additional services that might be 
needed to make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service April 11, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, the documentation shows 
that five units of this code were billed; however, only four units were tested (candida albicans, candida 
glabrata, candida lusitaniae, and candida dubliniensis). Based on this information, we decided that Medicare 
rules for coverage of procedure code 87481 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87481 for date of service April 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab (Prolia) (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the patient cannot afford Evenity, and is unable tolerate 
Fosamax. The Plan denied your request. The Plan says the patient does not meet the Part B Step Therapy 
requirements for Prolia (denosumab). 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of an 
intravenous (IV) bisphosphonate before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drug(s). Our reviewer also found that there is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve denosumab (Prolia) (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable partial denture (D5283). 
 
You asked the Plan to pre-approve removable partial denture. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removable partial denture (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D4263 and D4264) and guided 
tissue regeneration (D4266). 
 
You asked the Plan to pre-approve dental services. You say that in the areas where implants will be placed, 
bone grafting treatment has been planned. The Plan denied your request. The Plan says the codes requested 
appear to be incorrect because the teeth are planned to be extracted. 
 
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 dental 
services 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 dental services. Our reviewer says that 
these services are not medically necessary. Our physician reviewer found there was a letter from the dental 
provider stating that the enrollee has rampant decay, needs full mouth extractions, and the intent of the patient 
is to have implant supported restorations in the future. A full mouth series of x-rays were include dated August 
1, 2023, and rampant decay is noted. A periodontal record was also submitted. The decayed teeth are not 
restorable. D4263, D4264, and D4266 are dental procedure codes for natural teeth. The narrative states that all 
of the enrollees teeth will be extracted. The procedure codes requested are not appropriate in this situation as 
the bone graft is not being added to an area where there is a natural tooth. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone replacement grafts (D4263 and D4264) and guided tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says that the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our reviewer says that the 
CGM coverage criteria was met. Our physician reviewer found that the current criteria for a CGM requires 
insulin use. Although the last note from March of 2023 was from a time when the CGM requirements were for 
3 shots of insulin a day, since the enrollee is using insulin 1 time a day and the current requirements are for 
insulin use (even 1 time a day), it is reasonable to approve the CGM. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
  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: 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary.  
 
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 On review of the available records, the enrollee with debility and stroke as described 
above does not meet CMS coverage criteria for IRF admission. 
The enrollee is medically stable as mentioned above and does not need PMR physician's supervision 3 times a 
week in an IRF. 
 No acute rehab nursing needs documented. 
At the current functional level of max A to dependency, the enrollee is unlikely to make a significant functional 
progress in 7-10 days as predicted in the preadmission screening for IRF. 
The enrollee needs PT, OT and speech for a long time and does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
Document does not support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, 
and nursing needs (combined complexity does not require acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. 
The enrollee's rehab needs can be safely provided in an alternate and low intensity setting such as in an SNF.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical access to an implant body (D6011).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections via Cystoscopy (codes J0585 and 
52287). 
 
You asked the Plan to pre-approve Botox injections via Cystoscopy. You say that you are seeking a third line 
therapy option with the Cystoscopy with 200 units of Botox. The Plan denied your request. The Plan says the 
submitted documentation does not meet the coverage requirements or Medicare indications. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Botox injections via Cystoscopy. Our 
reviewer says that this request is not medically necessary. Our physician reviewer found bladder Botox 
injection is an acceptable and FDA approved third line treatment option for overactive bladder with urge 
incontinence.  However, in this case, the medical records do not show that the enrollee has failed first line 
therapy (behavior modification and pelvic floor therapy) and several second line treatment options 
(anticholinergics other than oxybutynin and beta-3 adrenergic agonists). Our reviewer also found that the 
records are not clear as to whether the artificial sphincter is working properly. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injections via Cystoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Botox injections via Cystoscopy (codes J0585 and 52287).
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 complexity of the enrollee's nursing, medical and 
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The Plan denied your request. The Plan says the enrollee's condition does not meet all of the requirements 
for inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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.  
 
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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen. We decided that the Plan does not have 
to pre-approve a CT scan of the pelvis.  
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis.. You say that the enrollee needs the 
requested CT scan. The Plan says that the requested CT is not medically necessary and does not satisfy the 
criteria for coverage. 
 
  We decided that the Plan has to pre-approve a CT scan of the abdomen.  
 
The rules say that CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. 
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the request for evaluation of the liver in a patient with even mild elevation of alkaline 
phosphatase makes sense despite the normal ultrasound. 
 
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 CT scan of the abdomen have been met. Therefore, we decided that the Plan 
has to pre-approve a CT scan of the abdomen.  
 
We also decided that the Plan does not have to pre-approve a CT scan of the pelvis. 
 
The rules say that CT scans are covered if there is literature to support its use for the patients condition and the 
scan is reasonable and necessary for the patient. 
 
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 CT scan of the pelvis. Our reviewer 
says that there are no clinical complaints referable to the pelvis, so the request is denied. 
 
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 CT scan of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the pelvis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95165 for date of service May 31, 2023. 
 
You asked the Plan to pay for procedure code 95165. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 95165 is professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses). 
 
We find that CPT code 95165 is not supported in the medical record. Specifically, the medical records 
submitted do not include a physician's order. This means the validity and accuracy of the service and units 
billed cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 95165 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
95165 for date of service May 31, 2023.