Persius/hicric huggingface dataset:
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 enrollee will beneift from acute inpatient rehab 
which cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission 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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve the parathyroid planar imaging. You say that this service is medically 
necessary. The Plan denied your request. The Plan says you do not meet the Plan's criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the parathyroid planar imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the review indicates that you have a history of Graves disease and a 
recurrence of hyperthyroidism. There is no documentation of any hypercalcemia or elevated parathyroid 
hormone level. There is no specific clinical rationale for the requested study. The review has determined that 
the items/services at issue in this case are 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 the parathyroid planar imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the parathyroid planar imaging (78070).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and mandibular partial denture 
(D5214). 
 
You asked the Plan to pre-approve core buildup and mandibular partial denture. You say that this is medically 
necessary. 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 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 core 
buildup (D2950) and mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion (96365, 96366), refilling and 
maintenance of a portable pump (96521) and an office visit (99214) provided on June 6, 2023. 
 
You asked the Plan to pay for intravenous infusion and an office visit. You say that see attached medical 
records to support the dispute for codes (99214), (96365), (96366), and (96521). The Plan denied your request. 
The Plan says codes 96365, 96366, 96521, 99214 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for intravenous infusion and an office visit. Our reviewer says 
that the services do not meet criteria for payment on this claim. Our reviewer found that for code 96365 and 
96366, the medical record describes intravenous insulin treatment provided for an outpatient on June 6, 
2023. In this case, there is a more appropriate code that should be reported for service provided. For code 
96521, the medical record does not include documentation of refilling and maintenance of portable pump. Was 
unable to cite report, as this procedure was not found in medical record. For code 99214, although 
documentation supports appropriate history/examination, moderate level of decision making is not supported. 
In this case, straightforward medical decision making is supported, and a more specific code would be reported 
for documentation submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion and an office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for intravenous infusion (96365, 96366), refilling and maintenance 
of a portable pump (96521) and an office visit (99214) provided on June 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Dalvance. 
 
You asked the Plan to pre-approve Dalvance. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 Dalvance. Our reviewer says that the 
enrollee does not meet criteria for Dalvance. Our physician reviewer found Dalvance is not Food & Drug 
Administration (FDA) approved for the enrollee's condition. This use is not supported by one of the major drug 
compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dalvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Dalvance.
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 August 11, 2023. 
 
You asked the Plan to pay for OIVIT services. 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. 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 August 11, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from May 31, 2023, to 
June 12, 2023. 
 
You asked the Plan to pay for SNF care. You say that you required extra help and care from the skilled nursing 
facility. The Plan denied your request. The Plan says that the denial of payment for this service is correct, 
because your current level of function does not require daily skilled therapy services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation provided, it is my opinion that the enrollee did qualify for 
ongoing SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have 
documented skilled therapy needs. Daily skilled services were required to establish a maintenance program and 
prevent deterioration of the enrollees condition prior to additional surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for skilled nursing 
facility (SNF) care provided from May 31, 2023, to June 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze, impregnated with other than water, normal saline, or 
hydrogel (A6223) provided on November 21, 2022. 
 You asked the Plan to pay for gauze. You say that you disagree with the denial. You have previously billed for 
60 units. The Plan denied your request. The Plan says the enrollee received the maximum allowable units for 
gauze in November 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gauze have not been met. Specifically, the records show that the provider billed for 60 units of 
gauze on November 17, 2022, which was only 15 days prior. The 60 units were shipped too early. Therefore, 
we decided that the Plan does not have to pay for gauze, impregnated with other than water, normal saline, or 
hydrogel (A6223) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 22, 2023, to May 30, 
2023, billed with procedure codes 99203, 97810 (16 units), 97811 (16 units), 97813 (16 units), and 97814 (16 
units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support codes 97811, 
97813, and 97814. Codes 99203 and 97810 are bundled and not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
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 pay for the practitioner services provided. Our 
reviewer says that documentation does not support the billed codes. Our coding reviewer found that codes 
97811, 97813, and 97814 are not supported. The procedure report includes insufficient documentation to 
confirm time spent, one on contact with patient, as well as reinsertion of needles per CPT code description. 
Therefore, documentation submitted for date of service billed, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. We have confirmed that code 99203 is a column 
II code to column I code 97810. The claim has not been billed with an appropriate modifier to bypass the edit. 
Also, code 97810 is a column II code to column I code 97813 with a modifier indicator of 0. The column II 
code is therefore not payable. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on May 22, 2023, to May 30, 2023, billed with procedure codes 99203, 97810 
(16 units), 97811 (16 units), 97813 (16 units), and 97814 (16 units).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methylprednisolone tablet. 
 
You asked the Plan to pre-approve methylprednisolone tablet. The Plan denied your request. The Plan says that 
self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methylprednisolone tablet.  
 
Benefits for methylprednisolone tablet may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laparoscopic repair of anterior abdominal hernia to 
be provided at an out-of-network (OON) facility.  
 
You asked the Plan to pre-approve the surgical service. You say that you are in-network with the enrollee's 
Plan. You say that your hospital closed. You also say that you have privileges at the requested facility. The 
Plan denied your request. The Plan says this service can be provided in-network. 
 
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 facility in this case is not a network facility with the Plan. The Plan has network facilities available where the items/services at issue in this appeal can be performed. 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 the laparoscopic repair of anterior abdominal hernia to be provided at an out-of-network (OON) 
facility.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation. 
 
You asked the Plan to pre-approve non-emergency transportation. You say that you need additional 
transportation so that you can get to your physical therapy appointments. The Plan denied your request. The 
Plan says additional trips beyond what the benefit allows are not covered. 
 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 a maximum of 18 one-way trips per year.  
 
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 non-emergency transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has chronic respiratory 
failure caused by severe COPD. You say that the enrollee is being treated with oxygen and BiPAP at home and 
despite this, their carbon dioxide is markedly elevated at 83 drawn while on a BiPAP with a rate. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary for this patient because their 
needs can be met with an alternative device such as a BiPAP device with average volume-assured pressure 
support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the home 
ventilator that is being requested for use in an average volume assured pressure support (AVAPS) mode which 
is a modality could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-
up rate. The enrollee has not tried and failed a BiPAP with AVAPS and a backup rate. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonpneumatic compression controller with sequential 
calibrated gradient pressure.  
 
You asked the Plan to pre-approve a nonpneumatic compression controller with sequential calibrated gradient 
pressure. You say that the item is medically necessary. The Plan denied your request. The Plan says this is 
considered experimental. 
 
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 a nonpneumatic compression controller 
with sequential calibrated gradient pressure. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental. 
 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 nonpneumatic compression controller with sequential calibrated gradient 
pressure have not been met. Therefore, we decided that the Plan does not have to pre-approve a nonpneumatic 
compression controller with sequential calibrated gradient pressure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 10, 2023. 
 
You asked the Plan to pay for lab tests. You say that this coding is accurate. The Plan denied your request. The 
Plan says there is a more appropriate lab panel code that should be used: 87999. 
 
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 84781 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The CPT Code Manual definition of code 87640 is 
infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique. The CPT Code Manual definition of code 87653 is infectious agent detection by 
nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The CPT Code Manual 
definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; 
amplified probe technique, each organism.  
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found the order does not specify which tests are included in the panel, which 
has not been defined by the American Medical Association. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not need the power options to qualify for a K0861 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a K0861 Group 3 power wheelchair with multiple 
power options may be covered if certain criteria 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 Group 3 power wheelchair. Our 
reviewer says that the enrollee does not meet criteria for this device. Our physician reviewer found the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity, or require an 
alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and 
accessories.