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

 
We decided that the Plan does not have to replace the charges for the inpatient hospital services provided from 
November 15, 2022, to December 8, 2022, noted on the itemized bill as CATH, INF, PER/CENT/MIDLINE, 
denied with reason code B.  
 
You asked the Plan to replace the charges for the inpatient services. You say that this claim was billed 
correctly, and the denied charges are supported. The Plan denied your request. The Plan says five of the six 
lines on the itemized bill that were denied were supported by appeal documentation. These charges were added 
back to the claim and paid. However, $504 in charge remain unsupported. 
 
The Plan follows Medicare rules. Medicare rules say that inpatient routine services are considered to be 
included in the room and board charge. All reported charges must be documented to support inclusion on the 
claim.  
 
We asked our coding 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 replace the charges for the inpatient services. Our 
reviewer says that the charges at issue were correctly removed from payment consideration. Our physician 
reviewer found the charges described by CATH, INF, PER/CENT/MIDLINE on November 22, 2022, and 
November 27, 2022, are not supported. There is no procedure note to document this service was performed.  
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to replace the charges for the inpatient hospital services provided from November 15, 2022, to 
December 8, 2022, noted on the itemized bill as CATH, INF, PER/CENT/MIDLINE, denied with reason code 
B.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) sensor kit. You asked the Plan to pre-approve a CGM sensor kit. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says the enrollee is not on 
insulin and does not have any documented hypoglycemia events. 
 
The Plan follows 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 a CGM sensor kit. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 CGM sensor kit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM) sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 office visits to be provided by an out-of-network 
(OON) provider.   

You asked the Plan to pre-approve 5 office visits to be provided by an OON provider.. 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. 
 
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. 
 
The provider at issue in this case is not a network provider with the Plan. 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 5 office visits. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found based on the medical records provided there is no documentation that 
the 5 additional OON neurology visits at issue in this case meet all Medicare criteria for medically reasonable 
and necessary for the enrollee as opposed to follow-up with an in-network provider. It is medically reasonable 
to await the results of the evaluation with the OON provider to determine if further OON services are indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 office visits have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve 5 office visits. Therefore, we decided that the Plan 
does not have to pre-approve 5 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer assisted surgical navigation (20985). 
 
You asked the Plan to pre-approve computer assisted surgical navigation. 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 computer assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested 
computer-assisted surgical navigation is not medically reasonable or 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 computer assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer assisted surgical navigation (20985).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve the 6 additional physical therapy visits. You say that the records provided 
support the need for the number of physical therapy visits requested. The Plan denied your request. The Plan 
says physical therapy visits beyond the 18 that were approved, are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not 
generally accepted as specific and effective therapy for the patient's condition beyond what was approved by 
the health plan. The records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. The enrollee has had ample therapy instruction to be able to transition to an independent home 
exercise program. The requested additional therapy sessions beyond what was approved are 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 6 additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Allograft Bioventus OsteoAMP (20930). 
 
You asked the Plan to pre-approve Allograft Bioventus OsteoAMP. 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 Allograft Bioventus OsteoAMP. Our 
reviewer says that Allograft Bioventus OsteoAMP Our physician reviewer found there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Bioventis OsteoAmp allograft is not medically reasonable or 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 Allograft Bioventus OsteoAMP have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Allograft Bioventus OsteoAMP (20930).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (rn) 
in the home health or hospice setting, each 15 minutes (G0299x4). 
 You asked the Plan to pre-approve home health services. You say that the enrollee cannot get in and out of bed. 
The home health services are needed. 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 although 
provided records document a need for home health physical and occupational therapy treatment, provided 
records in this case do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
No medical notes from the enrollees treating physician are provided documenting a need for skilled nursing 
services. Records do not document the need for intravenous medications, new tube feeding or ostomy care or 
complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (rn) in the home health or 
hospice setting, each 15 minutes (G0299x4).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 1, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent - per quadrant) 
(D4921) provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that this service was 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 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 March 29, 2023. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent - per 
quadrant) (D4921) provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests (K0195x13). 
 
You asked the Plan to pre-approve elevating leg rests. 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 elevating leg rests. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has normal range of motion in her lower extremities and no edema per 
physician note. She does not use intermittent catheterization or have high risk for pressure sores. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating leg rests have not been met. Therefore, we decided that the Plan does 
not have to pre-approve elevating leg rests (K0195x13).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watchman procedure and related transesophageal 
echocardiogram (93312, 33340). 
 
You asked the Plan to pre-approve a Watchman procedure and related transesophageal echocardiogram. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED) with the certain conditions. 
 
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 Watchman procedure and related 
transesophageal echocardiogram. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found provided records in this case do not document a formal shared decision-making 
interaction with an independent non-interventional physician using an evidence-based decision tool on oral 
anticoagulation. 
 
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 Watchman procedure and related transesophageal echocardiogram have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Watchman procedure and related 
transesophageal echocardiogram (93312, 33340).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service 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 May 11, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for therapeutic radiology simulation-aided field setting; simple  
(code 77280) provided on May 22, 2023. 
 
You asked the Plan to pay for therapeutic radiology simulation-aided field setting; simple (code 77280). You 
say that the claim was denied and should have been paid as claims previously for the same service were paid. 
The Plan denied your request. The Plan says that the requested therapeutic radiology simulation-aided field 
setting; simple is not medically necessary. A review of the current medical literature shows that the evidence is 
insufficient to determine long-term efficacy and safety data to support the routine use of electronic surface 
brachytherapy. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for therapeutic radiology simulation-aided field 
setting; simple (code 77280). Our reviewer says that the requested therapeutic radiology simulation-aided field 
setting; simple (code 77280) is considered medically reasonable and necessary in this case. Our physician 
reviewer found when treating skin cancers, or any cancer, one could justify a simulation (either complex or 
simple) prior to treatment planning and a simple simulation prior to the first treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic radiology simulation-aided field setting; simple (code 77280) have 
been met. Therefore, we decided that the Plan has to pay for therapeutic radiology simulation-aided field 
setting; simple (code 77280) provided on May 22, 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 an implantable infusion pump (62362, 62350, E0783). 
 
You asked the Plan to pre-approve an implantable infusion pump. You say that this is medically necessary. The 
Plan denied your request. The Plan says this can't be covered because the enrollee is no longer a member of the 
Plan. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable infusion pump is covered when used 
to administer opioid drugs for treatment of severe chronic intractable pain of malignant or nonmalignant origin 
in patients who have a life expectancy of at least 3 months, and who have proven unresponsive to less invasive 
medical therapy.  
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 an implantable infusion pump. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records do not 
include there is no documentation of a mental health examination. The requested procedure is not medically 
reasonable or 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 an implantable infusion pump have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable infusion pump (62362, 62350, E0783).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on January 10, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services were not paid. 
 
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. Review of the file shows that the services were denied as a duplicate. The 
documentation did not include a claim of which was paid and processed by the Plan for the initial services. No 
other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the ambulance services provided on January 10, 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.