Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still requires a lot of assistance and 
would benefit from more SNF services. The Plan denied your request. The Plan says that the request is not 
medically necessary. 
 
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 pre-approve 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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pre-approve a continuation 
of SNF care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim should be reprocessed due to medical 
necessity. The Plan denied your request. The Plan says the billed code is 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. 
 
We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee was 
seen for evaluation prior to a colonoscopy provided on the same day. The enrollee was stable and in no acute 
distress. The records do not show that a high level of decision making was provided. The records do not 
indicate the amount of time spent with the enrollee. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99223 billed for date of service June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occipital nerve decompression with fat graft neuroplasty 
(15771). 
 
You asked the Plan to pre-approve occipital nerve decompression with fat graft neuroplasty. You say that the 
requested services are a necessity for your care. The Plan denied your request. The Plan says the requested 
services are experimental/investigational. 
 
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 occipital nerve decompression with fat 
graft neuroplasty. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you have headache secondary to occipital neuralgia/ 
trigeminal neuralgia. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occipital nerve decompression with fat graft neuroplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve occipital nerve decompression with fat graft 
neuroplasty (15771).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is being maintained currently 
with bilevel positive airway pressure (BIPAP). The enrollee does not have data to support the escalation of 
therapy to home ventilator at this time. Hence, a home ventilator not indicated at this time per documentation 
and data provided.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 10, 2023, to 
February 8, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 10, 2023, to 
February 8, 2023.
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 May 23, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the services are not covered. 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 May 23, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided on January 9, 2023, billed with codes 93923 and 
93925. 
 
You asked the Plan to pay for the testing. You say medical records submitted support codes 93923 and 93925 
and should be paid. The Plan denied your request. The Plan says that there was insufficient documentation to 
support code 93923. The Plan also says that there was insufficient documentation to support code 93925. 
Therefore, both codes 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. In this case, the CPT Code Manual definition of 
code 93923 and 93925 is complete bilateral noninvasive physiologic studies of upper or lower extremity 
arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 
tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform 
recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior 
tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial 
indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen 
tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, 
measurements with postural provocative tests, or measurements with reactive hyperemia) (93923) and duplex 
scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925). 
 
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 testing. Our reviewer found that the medical records 
submitted were enough to support codes 93923 and 93925. The records submitted indicate complete bilateral 
noninvasive physiological studies of upper or lower extremity arteries, 3 or more levels were performed. The 
documentation also show that a complete duplex scan was done on both left and right extremities. There are no 
limitations or exclusions, which allows both 93923 and 93925 to be coded and billed together. 
 
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 tests have been met. Therefore, we decided that the Plan has to pay for the 
testing provided on January 9, 2023, billed with codes 93923 and 93925.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for dates of service from June 
18, 2023, to June 20, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you have billed and documented the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
service 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 99291 is not supported in the medical record. Specifically, we were unable to ascertain 
that the provided medical records are for the dates of service at issue. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for dates of service from June 18, 2023, to June 20, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push wheelchair with features (K0005, K0040, E2617, 
K0108, E2211, E2213, E2609, E0978, E2201, E2203, E0971, E0973 and E0974). 
 
You asked the Plan to pre-approve a wheelchair. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says Medicare does not cover durable medical 
equipment (DME) in a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a push wheelchair with features (K0005, K0040, E2617, K0108, E2211, 
E2213, E2609, E0978, E2201, E2203, E0971, E0973 and E0974).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns - porcelain fused to predominantly base metal 
tooth #'s 13 and 14 (D2751).  
 
You asked the Plan to pre-approve the crowns - porcelain fused to predominantly base metal. You say that you 
need replacement crowns for #13 and 14 to improve mastication function. The Plan denied your request. The 
Plan says your benefit for the crowns has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested crowns was exhausted on date of service July 19, 2019.  Therefore, we decided that the Plan does not have to pre-approve crowns - porcelain fused to predominantly 
base metal tooth #'s 13 and 14 (D2751).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 13, 2022, to 
October 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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 code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.9, described as acute 
kidney failure, unspecified. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the enrollee is a 70-year-old male who presented to the emergency 
department with rectal bleeding and had recently had the same complaint when he was administered blood 
transfusion. This time, hemoglobin was found to be 6.7 with blood urea nitrogen 20, creatinine 1.6 and was 
given intravenous fluids and medications resulting in a reduction of creatinine to 1.3. Baseline creatinine was 
noted to have been 1.4 based on provided documentation. The enrollee did not have sufficient evidence of 
acute kidney failure due to the fact that intravenous fluids led to quick reduction in creatinine, there was not an 
increase in creatinine of 0.3 mg/dL in 48 hours, increase in creatinine of 1.5 times baseline, increase creatinine 
to 4.0+ mg/dL without hydration, or evidence of significant oliguria.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 13, 2022, to October 18, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676, A9901) and 
surgical boot (L3260). 
 You asked the Plan to pay for a pneumatic compression device and surgical boot. You say that the items were 
medically necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative 
services and there is no indication the enrollee has diabetes or a brace. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that 
orthopedic shoes and other supportive devices for the feet generally are not covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676, A9901) and surgical boot (L3260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT solid tumor and Heme CGP genetic panel 
(81455) provided on May 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Also, the records do not show that the enrollee has a confirmed diagnosis cancer. We 
found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the 
Plan does not have to pay for the Tempus xT solid tumor and Heme CGP genetic panel (81455) provided on 
May 1, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87798, 87640, 87653, and 87500 for 
date of service January 30, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87798, 87640, 87653, and 87500. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are 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 codes 87481, 87798, 87640, 87653, and 87500 are not payable as billed. Specifically, there is 
a more appropriate lab panel code to be billed when one or more codes are included in the same panel. This 
means the codes are not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 87481, 87798, 87640, 87653, and 87500 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87798, 87640, 87653, and 87500 for 
date of service January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided to the enrollee on April 
28, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that  the diagnosis is appropriate for 
the services rendered. The Plan denied your request. The Plan says that medical nutrition therapy (MNT) is 
covered by Medicare only for diabetes and renal disease. 
 
  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy provided to the enrollee on April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018). 
 
You asked the Plan to pre-approve a Cala Trio device. 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 a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that this device is effective for the 
enrollee's tremor. The requested device is not the standard of care for this enrollee's tremor according to current 
guidelines.   
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018).