Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional six months continued use a of a home 
ventilator (E0466). 
 
You asked the Plan to pre-approve continued use a of a home ventilator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says at this time the requested device is not medically 
necessary beyond six months. 
 
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 continued use a of a home ventilator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Plan has approved the device for six months, pending 
additional testing. If this enrollee does have chronic CO2 retention, it appears the enrollee's needs could be met 
with bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during 
sleep. Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or 
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 continued use a of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional six months continued use a of a home ventilator 
(E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 49905 and 43235 billed for December 2, 
2021. 
 
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 procedure code 49905 is not supported and 43235 is inclusive to another billed code. 
 
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 49905 is omental flap, intra-abdominal (List separately in 
addition to code for primary procedure). 
 
We find that CPT code 49905 is not supported in the medical record. Specifically, there is no documentation of 
an intra-abdominal omental flap. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met.  
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that code 43235 billed with the -XS modifier is a distinct procedural 
service. Specifically, the records show that this service was inclusive to code 43117 and not a separate 
procedural service. Based on this information, we decided that Medicare rules for coverage of services billed 
with a -XS modifier have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 49905 and 43235 billed for 
December 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency wheelchair van transportation service 
(A0130), and ground mileage (A0425) provided on October 23, 2022. 
 
You asked the Plan to pay for the non-emergency wheelchair van transportation service and ground mileage. 
The Plan denied your request. The Plan says this is not covered. Your plan only covers an ambulance for 
emergencies. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the non-emergency wheelchair van transportation service (A0130), and 
ground mileage (A0425) provided on October 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) procedure 
for vertebra T10.  
 
You asked the Plan to pre-approve the requested PVA procedure. You say that both vertebral levels have 
compression fractures and should be treated to reduce symptoms. The Plan denied your request. The Plan says 
this procedure was approved only for the T12 level. The medical necessity of treatment of T10 is not 
supported.  
 
The Plan follows Medicare rules. Medicare rules say that treatment with PVA requires non-response to non-
surgical management such as medications, physical therapy, and bracing.  
 
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 PVA procedure. Our reviewer says that the requested surgery is not considered medically reasonable and necessary as the criteria are 
not met.  Our physician reviewer found the records do not include a trial of bracing to treat the enrollee's 
condition.  
 
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 PVA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebral augmentation (PVA) procedure for vertebra T10.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing services. 
 
You asked the Plan to pre-approve home health services. You say that the current 12 hours per week are not 
feasible for nurses to come every day in a timely manner. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. Your needs are custodial care needs. Therefore, additional skilled 
nursing care is not shown to be needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health skilled nursing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the dental service (D6111) is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service November 24, 
2022. 
 
You asked the Plan to pay for procedure code 99222. 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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee was treated in the hospital. 
The note from that date describe the enrollee presenting with anasarca two days prior with shortness of breath, 
brain natriuretic peptide and troponin elevations, and fever. Examination revealed stable/normal vitals, alter 
and oriented, pacemaker, no meningismus, irregular heart rhythm, and extremity edema. The enrollee was 
diagnosed with congestive heart failure, atelectasis, pleural effusion and blood cultures, urinalysis with culture, 
with empiric antibiotics were ordered. The provided documentation does not sufficiently support a 
comprehensive history or physical and did not describe medical decision-making of moderate complexity. 
Therefore, code 99222 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 for date of service November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service October 31, 
2022, to November 5, 2022. 
 
You asked the Plan to pay for procedure code 99231. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99231 is bundled into payment for code 36556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99231 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -25 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99231 billed for date of service October 31, 2022, to November 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490 for date of service February 15, 2023. 
 
You asked the Plan to pay for code J3490. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service is not payable 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. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed within 
the global surgery period for code 27096. Without an appropriate modifier, code J3490 is not separately 
payable as billed.  Based on this information, we decided that Medicare rules for coverage of code J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for code J3490 for date of service February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says that the dental service (D5225) is 
being denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve the dental 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve core buildup. 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 core 
buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit, x-ray, and drug 
injections provided on August 16, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit, x-ray, and drug injections. You say 
that this provider is in-network, and the services were medically necessary. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each in-network specialist office visit. Your contract with the Plan also clearly says that you 
must pay a $45 copayment for each in-network x-ray provided in a provider's office. Your contract with the 
Plan also clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $45 copayment for the x-
ray. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. You 
have also been asked to pay $0.52, which is 20% coinsurance of the allowed amount for the drug injection 
($2.58 allowed amount x 20% coinsurance = $0.52). This item/service falls within the Medicare Part B drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit, x-ray, 
and drug injections provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2954) provided on January 5, 2023. 
 
You asked the Plan to pay for D2954. You say that you do not agree with this denial. The Plan denied your 
request. The Plan says D2954 is not a covered benefit. 
 
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 pay for a core 
build-up (D2954) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - resin base (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot wait 5 years to get a new 
denture. 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 Plan's 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 on date of service April 14, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - resin base 
(D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional months of a continuous positive 
airway pressure (CPAP) device (E0601). 
 
You asked the Plan to pre-approve continued use of a CPAP device. You say that you disagree with the denial. 
The Plan denied your request. The Plan says a CPAP is covered for an initial three months for enrollees with 
sleep apnea. Additional time is covered if the CPAP helps you during the first three months. We will approve 
the requested rental of a CPAP machine for three months. We will not approve the additional five months. 
 
The Plan must follow Medicare rules. The rules say that a CPAP device may be covered 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 continued use of a CPAP device. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have obstructive 
sleep apnea, diagnosed with attended polysomnography on July 30, 2022. CPAP was prescribed October 17, 
2022. There is no subsequent visit with the medical provider, documented in the record, to assess compliance 
and benefit of the device. This is a Medicare requirement for continued coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a CPAP device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve five (5) additional months of a continuous positive airway pressure 
(CPAP) device (E0601).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - porcelain/ceramic (D6245) provided on January 18, 
2023. 
 
You asked the Plan to pay for pontic - porcelain/ceramic. 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 pay for pontic - 
porcelain/ceramic (D6245) provided on January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49320 billed for date of service February 9, 
2023.  
 
You asked the Plan to pay for procedure code 49320. You say that this should be paid for. The Plan denied your request. The Plan says payment for code 49320 is bundled into payment for code 44205.. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 49320 
is a column II code to column I code 44205 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 49320 billed for date of service February 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  skilled nursing facility (SNF) care provided on November 
30, 2022, through December 3, 2022. 
You asked the Plan to pay for  the SNF care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollee had reached their maximum covered stay. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 15, 2022, 
through November 29, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for  skilled nursing facility (SNF) care provided on November 30, 2022, 
through December 3, 2022.