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

 
We decided that the Plan does not have to pay for ambulance services provided on June 8, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you used the diagnosis code of S22.49XA 
for multiple fractures of ribs, unspecified side. You said that you would like assistance as to what code should 
have been billed instead. The Plan denied your request. The Plan says you did not bill these services with the 
correct diagnosis code to indicate laterality. 
 
The Plan must follow Medicare rules. Medicare rules say that when a condition exists on one side of the body, 
the diagnosis code billed should include the laterality of the condition. 
 In this case, you billed diagnosis S22.49XA for multiple fractures of ribs, unspecified side. However, the 
medical records clearly show that the rib fractures all occurred on the left side. As a result, the diagnosis code 
indicating the laterality (i.e., left side) should have been billed instead of the 'unspecified side' diagnosis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on June 8, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for dates of service June 26, 
2023, to June 29, 2023. 
 
You asked the Plan to pay for procedure code H2019. You say that this claim should be processed as in-
network. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2019 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2019 billed for dates of service June 26, 2023, to June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99214 billed for date of service July 14, 2023. 
 
You asked the Plan to pay for 99214. You say that 99214 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99214 is denied because it is not supported in the 
documentation. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter.  
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 99214. Our reviewer says that 99214 is not 
supported in the documentation. Our reviewer found the enrollee is a 75-year-old who was seen for an office 
visit for bladder cancer. Documentation indicated that the enrollee reported previous bleeding that has now 
resolved. A cystoscopy with biopsy was planned. The documentation showed a brief but appropriate history 
and examination, however, there was insufficient evidence of a moderate level of medical decision-making for 
this encounter or documentation of the duration of the appointment lasting 30-39 minutes, as required. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99214 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99214 billed for date of service July 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 16, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the Plan has paid so 
little. 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 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 item or service was exhausted on date of service September 11, 2023, and September 19, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on October 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each laboratory service provided on August 
21, 2023, to September 05, 2023. 
 
You asked the Plan to waive the copayment for each laboratory service. You say that you were unaware of the 
increase in the copayments. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for each laboratory service. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies 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. The total amount you owe is $120 ($40 
copayment x 3 services = $120). Therefore, we decided that the Plan does not have to waive the copayment for 
each laboratory service provided on August 21, 2023, to September 05, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom oral appliance. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a custom oral appliance is covered when specific 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has mild to moderate 
obstructive sleep apnea (OSA). A sleep study on May 19, 2023 showed an apnea-hypopnea index (AHI) of 9.4. 
She is symptomatic and has hypertension. She has refused treatment with continuous positive airway pressure 
(CPAP) therapy. Documentation of CPAP intolerance is only required when the AHI or respiratory disturbance 
index (RDI) is greater than 30. The criteria for coverage are met and the custom oral appliance is reasonable 
and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a custom oral appliance.  
 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 pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that without a chair you will fall down. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0858) and accessories 
(E2359, E2377, E2300, E2311, E2313, E2607, E1012, E0955, E1028). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for a group 3 as no 
qualifying diagnosis and/or no documentation of spasticity therefore there is no need for group 3 suspension. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Although the 
enrollee's condition may meet criteria for a power wheelchair, the criteria for this specifically requested power 
wheelchair are not met. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0858) and accessories 
(E2359, E2377, E2300, E2311, E2313, E2607, E1012, E0955, E1028).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve RFA of the genicular nerves. You say that the enrollee is in pain and this is 
the next level support to relieve discomfort. You say the enrollee's ability to regain maximum function is in 
jeopardy. The Plan denied your request. The Plan says the request is not medically necessary as current medical 
literature has not proven this procedure to be beneficial for knee pain. 
 
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 RFA of the genicular nerves. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. It is the 
subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 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 RFA of the genicular nerves have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic maintenance therapy provided from May 4, 2023, to 
September 6, 2023. 
 
You asked the Plan to pay for chiropractic maintenance therapy. You say that this is covered by your Plan. The 
Plan denied your request. The Plan says that these services are not covered by 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 rules say also that the only chiropractic service Medicare covers is manual manipulation of the 
spine to correct a subluxation. However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. 
For that reason, the Plans coverage rules apply in this case. The Plan covers routine chiropractic therapy 
services. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that although the Plan is correct that the services at issue are not 
covered by Medicare, they have not provided any reason the services are not covered under the additional 
chiropractic benefit. Therefore, we decided that the Plan has to pay for chiropractic maintenance therapy 
provided from May 4, 2023, to September 6, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve teriparatide self-injections. 
 
You asked the Plan to pre-approve the medication. You say that this medication is reasonable and necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 teriparatide self-injections.  Benefits for the medication 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission from December 29, 2022, through January 4, 
2023. 
 
You asked the Plan to pay for the inpatient admission from December 29, 2022, through January 4, 2023. You 
say that the services were medically necessary. The Plan denied your request. The Plan says that no hospital 
admission was authorized at the time of admission or prior to the enrollee's death despite the insurance 
information being presented. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 admission from December 29, 
2022, through January 4, 2023. Our reviewer says that the patient was not stable for transfer on any dates of 
service. Our physician reviewer found the review indicates that on presentation the enrollee was evaluated and 
admitted. She had jaundice and decompensated liver disease and pneumonia. She was diagnosed with 
pancreatic cancer and treated for encephalopathy. Her condition required intensive care level of care services 
and vasopressor therapy. She expired on January 4, 2023. The review has determined that the treating physician 
documented (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any 
dates of 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 the inpatient admission from December 29, 2022, through January 4, 2023, 
have been met. Therefore, we decided that the Plan has to pay for the inpatient admission from December 29, 
2022, through January 4, 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 pre-approve a nebulizer with compressor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a nebulizer is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has arthritis, diabetes, and 
hypertension. The medical records consist of a visit to establish care on February 14, 2023. A previous 
pneumonia is noted. She denies dyspnea but diffuse expiratory wheezing without distress was noted on exam. 
There is no documented trial of therapy with a metered-dose inhaler. There is no evidence of a more recent 
medical visit. The records do not contain results of pulmonary function testing and there is no diagnosis of 
chronic obstructive pulmonary disease (COPD) or asthma. The criteria for coverage are not met and the 
nebulizer with compressor is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a nebulizer with compressor.
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 needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in a lower level of 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ozempic injection 2mg/3ml. 
 
You asked the Plan to pre-approve the medication. You say that the injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 
 
 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 the Ozempic injection 
2mg/3ml.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.