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

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services under code 
99205, provided on June 28, 2022. 
 
You asked the Plan to pay for procedure code 99205. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient who has not received 
any professional services from the physician or physician group practice within the previous 3 years. 
 
In this case, the enrollee was seen by another provider within the same physician group practice on April 8, 2022. This is not a new patient per Medicare rules. Therefore, we decided that the Plan does not have to pay for 
the evaluation and management (E&M) services under code 99205, provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the travel and room/board expenses 
related to a lung transplant from April 14, 2022, through June 1, 2022. 
 
You asked the Plan to provide reimbursement for the travel and room/board expenses. You say that you are 
requesting the reimbursement for the transplant related travel and lodging as described in your benefits. The 
Plan denied your request. The Plan says this transplant was not approved by the Plan, nor covered by the Plan, 
as it was provided through Veterans' Administration (VA) coverage. Since this was not a Plan sponsored 
transplant, the travel/lodging reimbursement is not available. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must provide reasonable travel and lodging 
for transplants only when the transplant is provided at a Plan-offered location which is more distant than what 
is available to original Medicare beneficiaries who reside in the service area.  
 We looked at the file and Medicare rules. In this case, the distant location of the transplant center was not 
required by the Plan. The transplant center was elected by the enrollee due to coverage under the VA, 
according to the Plan's documents. These expenses are only reimbursed when the enrollee is using a further 
than usual location based on the Plan's internal guidelines, not due to enrollee choice. Based on this 
information, we decided that Medicare rules for coverage of the travel and room/board expenses have not been 
met. Therefore, we decided that the Plan does not have to provide reimbursement for the travel and room/board 
expenses related to a lung transplant from April 14, 2022, through June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve evaluation and management services. You say that you need to see a 
specialist. You say that your condition is getting worse. You say that it is hard to swallow. You also say that 
food is getting stuck in your throat. The Plan denied your request. The Plan says are network providers 
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 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76856) provided on March 4, 2022. 
 
You asked the Plan to pay for procedure code 76856. You say that the medical records support the billing of 
code 76856. The Plan denied your request. The Plan says the medical records do not support the billing of code 
76856. 
 
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 76856 is Ultrasound, pelvic (nonobstetric), real time with 
image documentation; complete. 
 
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 procedure code 76856. Our reviewer says that the medical 
records do not support the billing of code 76856. Our reviewer found the medical records do not support the 
use of procedure code 76856 as being a complete ultrasound being performed. Medical records support limited 
ultrasound was performed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76856 have not been met. Therefore, we decided that the Plan 
does not have to pay for the Ultrasound (76856) provided on March 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 76000 and 93281 provided on February 3, 2022, to 
February 4, 2022. 
 
You asked the Plan to pay for procedure codes 76000 and 93281. You say that the medical records support the 
billing of codes 76000 and 93281 with modifier 59. The Plan denied your request. The Plan says that the 
medical records do not support the billing of codes 76000 and 93281 with modifier 59. 
 
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 76000 is Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care 
professional time. The definition of code 93281 is Programming device evaluation (in person) with iterative 
adjustment of the implantable device to test the function of the device and select optimal permanent 
programmed values with analysis, review and report by a physician or other qualified health care professional; 
multiple lead pacemaker system. 
 
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 procedure codes 76000 and 93281. Our reviewer says that 
the medical records support the billing of codes 76000 and 93281 with modifier 59. Our reviewer found 
modifier 59 is being used appropriately as per NCCI edits as there is a column two relationship between 93281 
and 76000 with procedure code 33249. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 76000 and 93281 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 76000 and 93281 provided on February 3, 2022, to February 4, 2022.  
 
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 pre-approve a lumbar epidural steroid injection. 
 You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are only covered 
for certain indications. 
 
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 lumbar epidural steroid injection. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee a history of right lower extremity pain. The pain is 
continuous and is worse with sitting and lying down. The most recent physical exam on August 4, 2022 and 
electrodiagnostic testing do not indicate significant findings that would cause lumbar radiculopathy, radicular 
pain, or neurogenic claudication. Electrodiagnostic testing on June 20, 2022 revealed no evidence of a right 
lumbar radiculopathy. The lumbar magnetic resonance imaging (MRI) findings from August 23, 2022 do not 
indicate significant disc herniation, osteophyte, or osteophyte complexes, severe degenerative disc disease, 
foraminal or central spinal stenosis that would cause a concordant radiculopathy or radicular pain affecting the 
medial thigh. Therefore, the enrollee does not meet criteria for the requested services. 
 
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 lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation (HFCWO) 
system. 
 
You asked the Plan to pre-approve a HFCWO system. 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 follows Medicare rules. Medicare rules say that HFCWO devices are 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 a HFCWO system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the high frequency chest wall oscillation system at issue in this case 
meets all of Medicare's Local Coverage Determination (LCD): High Frequency Chest Wall Oscillation Devices 
- L33785 criteria for medically reasonable and necessary for the enrollee. Provided records do not document a 
diagnosis of cystic fibrosis, bronchiectasis or neuromuscular disease as required by the LCD. 
 
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 HFCWO system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation (HFCWO) system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that additional therapy is needed, you still need 
assistance with your movement. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that you are appealing the denial of the 
Freestyle Libre. The Plan denied your request. The Plan says the enrollee is not on insulin and does not meet 
the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and sensor. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has diabetes. The Plan denied your 
request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 Freestyle Libre continuous glucose monitor (CGM) and sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc 15MG/ML syringe (CPT code J7324). 
 You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says drugs in the Plan's Specialty Tier are not eligible for this type of exception. The 
Plan states they do not lower the cost-sharing amount for drugs in this tier. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. The Medicare rule in the Parts C 
& D Enrollee Grievances, Organizations/Coverage Determinations, and Appeals Guidance explains when you 
can get a tiering exception. It says you cannot get a tiering exception for very high-cost drugs on a specialty 
tier. The information we have says this is a very high-cost drug on a specialty tier. You do not qualify for a 
tiering exception per Medicare rules. Therefore, we decided that the Plan does not have to pre-approve 
Orthovisc 15MG/ML syringe (CPT code J7324).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot insert, removable, molded to patient model, UCB 
type, Berkeley Shell, each (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the Podiatrist had fitted you with a temporary 
set of orthotics that would correct both feet and enable you to place your feet in the shoes at the correct 
position. However, the orthotics were not the rigid type and quickly lost shape and became ineffective. 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 insert, removable, molded to 
patient model, UCB type, Berkeley Shell, each (L3000).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral surgery, bone removal from mouth. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you need a bone removed in your 
mouth in order for your dentures to fit properly. The Plan denied your request. The Plan says this request is not 
approved as no supporting clinical information was sent. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the surgical procedure have been met. 
Medical records were needed from the provider. The records show that the provider refuses to send over 
clinicals because there is no medical necessity for the procedure. The records show the Plan made attempts to 
obtain records without success. Therefore, we decided that the Plan does not have to pre-approve the oral 
surgery, bone removal from mouth.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for 12 years and has failed 12 months of conservative approaches to treatment. You say that this 
treatment is considered safe and effective, and authorization should be approved. The Plan denied your request. 
The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is considered experimental, and more research is 
needed. 
 
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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary for 
the evaluation of recurrent sinusitis. The Plan denied your request. The Plan says the requested CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found sinus CT scans are generally not 
recommended for evaluation of acute flares of chronic rhinosinusitis. The enrollee does not appear to have 
atypical symptoms. It has not been shown that a CT scan is necessary for surgical planning or evaluation of 
unique anatomy 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device has been determined to be of uncertain value. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). There remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.