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

 
We decided that the Plan does not have to pay for hyperbaric oxygen treatment (G0277) provided on December 
13, 2019. 
 
You asked the Plan to pay for hyperbaric oxygen treatment. You say that this was medically necessary. The 
Plan denied your request. The Plan says this 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 G0277 is hyperbaric oxygen under pressure, full body 
chamber, per 30 minute interval. 
 
We find that CPT code G0277 is not supported in the medical record. Specifically, four units of this code were 
billed, designating four 30 minute intervals. The records indicate that the total treatment time on this date of 
service was 15 minutes. Based on this information, we decided that Medicare rules for coverage of hyperbaric 
oxygen treatment have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric 
oxygen treatment (G0277) provided on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MAZE procedure with inpatient hospital care. 
 
You asked the Plan to pre-approve a MAZE procedure with inpatient hospital care. You say that the requested 
MAZE procedure with inpatient hospital care is medically necessary. The Plan denied your request. The Plan 
says the requested MAZE procedure with inpatient hospital care is not medically necessary. 
 
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 MAZE procedure with inpatient 
hospital care. Our reviewer says that the requested MAZE procedure with inpatient hospital care is not 
medically necessary. Our physician reviewer found surgical options for patients with atrial fibrillation can be 
considered when medical therapy and percutaneous ablative options have proven ineffective.  If ablation were 
thought to be medically necessary, current guidelines do not recommend a surgical approach to ablation over 
conventional percutaneous ablation.  While a surgical approach to ablation may have shown promise in a few 
centers it is not an accepted standard of practice in the medical community and has not been shown to be 
superior to existing accepted approaches to atrial fibrillation ablation. Maze procedures are considered 
appropriate when performed in conjunction with other heart surgery that already requires being on a pump such 
as valve replacement or coronary artery bypass, neither of which this enrollee requires.  There are presently 
NIH sponsored trials currently enrolling patients to assess whether or not a hybrid approach to ablation may be 
preferred in certain patient populations compared to established ablation procedures.  Therefore, at this time, 
the surgical ablation procedure should be considered investigational. 
 
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 MAZE procedure with inpatient hospital care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a MAZE procedure with inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 22, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram (93000). You say that you would like reconsideration 
because this is a covered service. The Plan denied your request. The Plan says utilization of network providers 
is required when possible and available. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 medical services provided on April 22, 2019 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that continued care can be provided at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional level tolerates an intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a male external catheter (A4349), urinary drainage bag 
(A4358) and intermittent urinary catheter (A4353) provided on March 24, 2020.   
 
You asked the Plan to pay for the catheters and supplies. You say that you would like reconsideration because 
the supplies are medically necessary The Plan denied your request. The Plan says the documentation submitted 
did not include a billing/shipping invoice to verify the billed supply. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice to verify the billed supplies. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a male external catheter (A4349), urinary drainage 
bag (A4358) and intermittent urinary catheter (A4353) provided on March 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that you have a chance for a better outcome at 
the requested facility. The Plan denied your request. The Plan says the services are available within the 
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 provider in this case is not a network provider with the Plan. 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 these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a So Clean CPAP sanitizing device. 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says a So Clean CPAP sanitizing device is hygienic and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a So Clean CPAP sanitizing device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the requested PBRT is medically necessary. The Plan 
denied your request. The Plan says the requested PBRT is not medically necessary. 
 
 
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 PBRT. Our reviewer says that the 
requested PBRT is not medically necessary. Our physician reviewer found for this enrollee, they plan to use 15 
fractions of proton therapy and it is not clear what is being offered for motion management.  It is possible that 
such an approach is inferior to SBRT. 
 
From a 2016 Consensus Statement on Proton Therapy in Early-Stage and Locally Advanced Non-Small Cell 
Lung Cancer the authors summarize the literature and ongoing studies, describe potential limitations and 
indications of proton therapy, and conclude: Promising preliminary clinical outcomes have been reported for 
patients with early-stage or locally advanced NSCLC who received proton therapy. However, the expense and 
technical challenges of proton therapy demand further technique optimization and more clinical studies. A one-
size-fits-all approach does not apply for any treatment including proton therapy. Therefore, we cannot provide 
generalized statements about proton therapies being of universal benefit to all patients for both early-stage and 
locally advanced lung cancers. 
  
In summary, there is no evidence that proton therapy is needed over other accepted treatments. There is no 
plausible reason that proton therapy would be more beneficial than standard therapy for this particular 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 PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray, professional component, provided on May 12, 2020. 
 
You asked the Plan to pay for the radiologic examination, chest; 2 views (71046). You say that the procedure 
was performed at the request of the referring doctor. The Plan denied your request. The Plan says that the chest 
x-ray was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the radiologic examination, chest; 2 views 
(71046). Our reviewer says that the service was considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee's smoking history does put the enrollee at increased risk for 
malignancy. The chest x-ray which was done has some limitations in the detection of lung cancer but is an 
adequate screen at the enrollee's age since the enrollee would not have qualified for a low dose lung CT which 
is the better and more sensitive test. To qualify for same the enrollee must be at least 55 years of age. 
 
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 radiologic examination, chest; 2 views (71046) have been met. Therefore, 
we decided that the Plan has to pay for the chest x-ray, professional component, provided on May 12, 2020.  
 
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: Favorable

 
We decided that the Plan has to pay for durable medical equipment provided to the enrollee on December 31, 
2019. 
 
You asked the Plan to pay for the DME. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate 
the specific supplies, or an itemized proof of delivery. 
 
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 the denied codes is: 
 
HCPCS A4353: 
 
Intermittent urinary catheter, with insertion supplies 
 
HCPCS A4349: 
 
Male external catheter, with or without adhesive, disposable, each 
 
HCPCS A4358: 
 
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each 
 
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 DME. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our coding reviewer found the medical 
records submitted include an itemized shipping/billing invoice indicating the specific supplies as well as
Proof of deliver to enrollee's address. The provided documentation meets criteria referenced by Medicare. 
 
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 DME have been met. Therefore, we decided that the Plan has to pay for 
durable medical equipment provided to the enrollee on December 31, 2019.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 5, 
2020 to March 31, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed for payment. The Plan 
denied your request. The Plan says the claim was not submitted with a treatment authorization code; therefore, 
the claim cannot be reprocessed without a corrected claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment 
authorization code. 
 
The case file did not contain a valid treatment authorization code. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for home health services provided to the enrollee from March 5, 2020 to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wearable mobile cardiovascular 
telemetry provided from February 12, 2020, to April 17, 2020. 
 
You asked the Plan to waive the coinsurance for the wearable mobile cardiovascular telemetry. You say that 
you cannot help that the provider was out of network. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment if supplied by the physician, whether in network or out of network.  
 
You have been asked to pay 20% coinsurance for the wearable mobile cardiovascular telemetry. The wearable 
mobile cardiovascular telemetry falls within the durable medical equipment benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the wearable mobile cardiovascular telemetry provided from 
February 12, 2020, to April 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zorvolex. 
 
You asked the Plan to pre-approve Zorvolex. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Zorvolex is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Zorvolex.  
 
Benefits for Zorvolex 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eligard. 
 
You asked the Plan to pre-approve Eligard. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Eligard.  
 
Benefits for Eligard 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition could be managed by continuing care in a skilled 
nursing facility. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 admission to a long term acute care hospital (LTACH) for the enrollee.