Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service February 1, 
2023 to February 23, 2023. 
 
You asked the Plan to pay for procedure code 99601. You say that this service was medically necessary. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service February 1, 2023 to February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has severe lung disease and 
requires the ventilator in order to breathe properly. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for approval of the ventilator. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
interstitial lung disease with pulmonary hypertension and bronchitis. Provided records document that the home 
ventilator is being requested for use in a volume assured pressure support mode which is a modality which 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up 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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on January 17, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 code 99214 is not supported in the medical record. Specifically, the claim did not include the 
location the service was provided. Based on this information, we decided that Medicare rules for coverage of 
the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit 
(99214) provided on January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is suitable and stable for 
transfer to an LTACH. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another 25 to 30 
days to continue complex respiratory medical care, daily multi-specialty physician follow ups, daily labs, 
physical and occupational therapy.  The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee can safely receive the services they need in the current hospital setting.  
 
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 that the enrollee is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that you need a new denture because your old 
denture is cutting your gums. 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 the date of service of March 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested services. 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. This benefit includes the 
requested maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth and mandibular partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) but is limited to one every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered D5213 on date of service January 26, 2021, and a covered D5214 on date of 
service July 13, 2022. Therefore, these benefits have been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework 
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you urgently need the custom orthotics as you 
have been in a lot of pain on your feet and are unable to walk. You also say that you have plantar fasciitis, 
neuropathy, and bone spurs. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver.  
You asked the Plan to pre-approve the Dexcom G7 receiver. You say that your primary care thought the CGM 
would be necessary and the best way to  handle your diabetes. The Plan denied your request. The Plan says the 
information provided by your doctor did not meet the requirements for covering this product. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the Dexcom G7 receiver have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 receiver.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. You say that pembrolizumab is the best treatment option 
for the enrollee The Plan denied your request. The Plan says this drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pembrolizumab. Our reviewer says that 
the requested use of pembrolizumab is not FDA-approved for the enrollees diagnosis. Our physician reviewer 
found the use of pembrolizumab is not supported by one of the major drug compendia or by clinical research. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canal retreatment on a premolar (D3347). 
 
You asked the Plan to pre-approve root canal retreatment on a premolar. You say that the service is necessary. 
The Plan denied your request. The Plan says the requested service is not covered. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve root 
canal retreatment on a premolar (D3347).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Brovana. 
 
You asked the Plan to pre-approve a tier exception for Brovana. You say that the exception is needed. The Plan 
denied your request. The Plan says the items do not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a tier exception for Brovana.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation 
(CCM) system (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart CCM. 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 an Optimizer Smart CCM. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, the CCM system would not be considered to be 
medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart CCM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart cardiac contractility modulation (CCM) system (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services out of the Plan's service area. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you need the physical therapy 
services for an ongoing issue while you are out of the area.  The Plan denied your request. The Plan says 
network providers are available to render necessary care. The requested services are not urgent or emergent.  
 
Medicare rules say that the plan must pay for emergency and urgently needed services. The rules say that 
urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable 
to get the services from the plan. Generally, these services are needed while the enrollee is outside of the 
service area. 
 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 physical therapy services. Our 
reviewer says that the requested physical therapy services are not considered medically necessary in this case. 
Our physician reviewer found that you do not have emergent or urgent therapy needs and have access to 
standard therapy services for back pain in-network. 
 
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 physical therapy services have not been met.  
 
The Plan has network providers available who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve the physical therapy services. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy services out of the Plan's service area.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's complex medical history including 
cancer requiring chemotherapy and Libtayo, hypertenson, Diabetes, and Dementia, recovery of the deficits 
noted in the physical therapy evaluation is not anticipated without intense and frequent skilled physical therapy 
along with a 24 -hour nursing care and services to facilitate improvement and prevent further decline. The Plan 
denied your request. The Plan says the enrollee's records do not show that you require skilled nursing or skilled 
rehabilitation services. Services needed may be provided safely in a lower level of care. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique (87460-59) provided on January 18, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service 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, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 service. Our reviewer found based on the medical records 
provided in this case (the lab order form and nothing else) there is no documentation that support that CPT 
code 87640 was distinct from CPT code 87641. Code 87641 (detection of methicillin-resistant staphylococcus 
aureus) was billed and paid.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique (87460-59) provided on January 18, 2023.