Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry (93229) 
provided on February 23, 2023. 
 
You asked the Plan to pay for the external mobile cardiovascular telemetry. You say that this service was 
medically necessary, and it was reported correctly. The Plan denied your request. The Plan says this code is not 
supported in the medical record. 
 
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 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible electrocardiogram (ECG) data storage (retrievable with query) with ECG triggered and patient 
selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and 
emergent data reports as prescribed by a physician or other qualified health care professional. 
 
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 external mobile cardiovascular telemetry. Our reviewer 
says that the billing this procedure code is not supported. Our reviewer found that the medical records do not 
support the use of procedure 93229 being performed on February 23, 2023. There is a more appropriate code to 
signify the reading and analyzing of the monitor on the enrollee for seven days. 
 
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 external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pay for the external mobile cardiovascular telemetry (93229) provided 
on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival flap procedure, including root planing-one to 
three contiguous teeth or tooth bounded spaces per quadrant (D4241), the bone replacement graft-of a retained 
natural tooth-first site in quadrant (D4263), and the guided tissue regeneration-resorbable barrier, per site 
(D4266) provided on March 1, 2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy.  
  
 
 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival flap 
procedure, including root planing-one to three contiguous teeth or tooth bounded spaces per quadrant (D4241), 
the bone replacement graft-of a retained natural tooth-first site in quadrant (D4263), and the guided tissue 
regeneration-resorbable barrier, per site (D4266) provided on March 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an MRI provided on March 31, 2023. 
 
You asked the Plan to waive the coinsurance for an MRI. You say that you were not advised that you would be 
responsible for the MRI copayment. 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 20% 
coinsurance up to $75 per day for diagnostic radiology services.  
 
 
  You have been asked to pay $57.29, which is 20% of the allowed amount for an MRI ($286.46 allowed x 20% 
= $57.29). This item/service falls within the outpatient diagnostic tests 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 coinsurance for an MRI provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #14 provided on April 25, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the dental service was medically necessary, and 
the service was needed to restore the tooth with a crown. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the core buildup is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #14 provided on April 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has decreased functional mobility. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 that the documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right transforaminal steroid injection at L3-L4 
(64483). 
 
You asked the Plan to pre-approve a steroid injection. You say that this injection is medically necessary. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an ESI is covered when the criteria listed in the 
Medicare rules section are met. 
 
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 steroid injection. Our reviewer says 
that the injection is not medically necessary. Our physician reviewer found that based on the medical records 
provided there is no documentation that the ESI at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. The provided records do not document imaging showing foraminal 
or central spinal stenosis. The records do not document post-laminectomy syndrome or acute herpes zoster 
associated pain.  
 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 steroid injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a right transforaminal steroid injection at L3-L4 (64483).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (OT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested services are not medically reasonable and 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 therapy services. 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 enrollee has been authorized to have up to 10 sessions of skilled 
therapy to improve her function. Without additional medical records stating she still has a significant deficit in 
function after the initial therapy is complete, the additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve occupational therapy (OT) services.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided by the requested licensed independent clinical 
social worker (LICSW) from June 2, 2022, to December 6, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this provider has been enrolled in Medicare since 
June 2, 2022 and you have provided the enrollment letter from Medicare. The Plan denied your request. The 
Plan says that the CMS guidelines clearly states that Licensed Professional Counselors are not eligible to 
participate in Medicare.  
 
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. Specifically, the Plan has not provided documentation showing this provider is a 
Licensed Professional Counselor and not a LICSW to substantiate their denial. Therefore, we decided that the 
Plan has to pay for psychotherapy provided by the requested LICSW from June 2, 2022, to December 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the scan is needed to differentiate between an 
FTD or AD diagnosis. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is believed to have a 
neurodegenerative disorder. However, she is not noted to meet diagnostic criteria for both AD and FTD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy for 
decompression of neural elements (0275T). 
 You asked the Plan to pre-approve a percutaneous decompression. You say that you believe the enrollee is an 
excellent candidate for this therapy, as this case demonstrates medical necessity. The Plan denied your request. 
The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PILD is covered for beneficiaries with LSS who are 
enrolled in an approved clinical study. 
 
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 percutaneous decompression. Our 
reviewer says that the procedure is not medically necessary. Our physician reviewer found that the enrollee is 
noted to have lumbar spinal stenosis. This enrollee is not enrolled in any clinical studies. This requested 
procedure is only supported in the setting of enrollment into a clinical study. Therefore, there are limitations as 
listed in the NCD that would prevent 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 a percutaneous decompression have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy for decompression of neural 
elements (0275T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 02, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support the services. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on May 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 60 one-way trips that do not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and 
accessories. 
 
You asked the Plan to pre-approve the CGM supplies and accessories. You say that the medical records support 
the need for the CGM, supplies and accessories.  The Plan denied your request. The Plan says  under Medicare 
guidelines your request is not medically necessary. 
 
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 the CGM supplies and accessories. Our 
reviewer says that the CGM, supplies and accessories are not medically necessary. Our physician reviewer 
found you have a past medical history with diabetes mellitus, hypertension and chronic obstructive pulmonary 
disease. You were evaluated by your provided on June 30, 2023 and you reported that you have difficulty 
performing finger sticks. You are not using insulin to control your diabetes. You do not meet coverage criteria 
for a CGM and accessories as they are not medically necessary or reasonable. 
 
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 supplies and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and accessories.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that a home ventilator is not medically necessary. 
 
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. 
 
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. Our reviewer says 
that a home ventilator is medically necessary. Our physician reviewer found that the enrollee has documented 
COPD and obstructive sleep apnea and requires continuous positive airway pressure therapy but did not 
tolerate use. The enrollee has a documented need for a ventilator. 
 
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 have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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 spinal surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve spinal surgery to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. 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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
spinal surgery to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation facility admission.  
The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting 
do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
humerus fracture and hip fracture after a fall.  Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.