Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound filler dressing billed with code A6199 provided 
on July 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 wound filler dressing billed with code A6199 
provided on July 22, 2022, 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 portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you are having a difficult time using your 
current equipment while you are away from home. The Plan denied your request. The Plan says the services are 
not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 chiropractic care provided on July 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc NP procedure. 
 
You asked the Plan to pre-approve a VIA Disc NP procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VIA Disc NP procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the VIA disc NP procedure is experimental for back pain. 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 a VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a VIA Disc NP procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050 x 2) purchased on 
November 21, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids in this case are 
not payable as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when rendered by participating provider in the Plans hearing vendor network.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when rendered by a participating provider in the Plans hearing vendor network. However, the hearing 
aids in this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not 
have to issue reimbursement for the hearing aids (V5050 x 2) purchased on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 24, 
2022. 
 
 
You asked the Plan to pay for the pneumatic compression device 
. You say that this device was provided for use during the patient's surgery. 
 The Plan denied your request. The Plan says equipment used in a facility for a procedure is not separately 
payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve Stereotactic body radiotherapy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says conventional radiotherapy is more appropriate. 
 
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 Stereotactic body radiotherapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found standard treatment would be dose-escalated conventional radiotherapy. As this 
patient has an unltracentral target, SBRT would conceivable be associated with excessive toxicity risks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Stereotactic body radiotherapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Stereotactic body radiotherapy (SBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new office visit and follow up visit for Botox 
injections to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a new office visit and follow up visit for Botox injections to be provided by 
an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your 
request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The 
Plan says there are equally qualified in-network specialists available to you that can provide the services you 
are requesting. 
 
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 
a new office visit and follow up visit for Botox injections 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 digital oral thermometer (A4931) and HEPA filter and 
supplies (E1399). 
 
You asked the Plan to pre-approve the thermometer and air filter. You say that you need a new HEPA filter and 
you also need a new thermometer because the current air filter and thermometer are no longer working 
properly. The Plan denied your request. The Plan says these items do not primarily serve a medical purpose and 
are not covered. 
 
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 digital oral thermometer (A4931) and HEPA filter and 
supplies (E1399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0152, G0151). 
 
You asked the Plan to pre-approve home health services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or falls or injuries which would 
necessitate any further skilled therapy visits beyond what has already been approved 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0152, G0151).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that for the past 10 days you have not had physical 
therapy. The Plan denied your request. The Plan says that you have used 100 days of SNF care. 
 
Medicare rules say Medicare plans must make reasonable and diligent efforts to gather and forward 
information to the Independent Review Entity (IRE). The Plan failed to provide information to substantiate you 
have used 100 SNF days. Without this information, we are unable to determine how many SNF days have been 
used. Therefore, we decided that the Plan must pre-approve SNF care. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the low frequency, non-contact, non-
thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for 
ongoing care, per day (97610) provided on April 25, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
 
  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
this service have not been met. Specifically, the ultrasound service provided in this case is not covered under 
the acupuncture benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the low 
frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound 
assessment, and instruction(s) for ongoing care, per day (97610) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2212 billed for July 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G2212 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 G2212 is prolonged office or other outpatient evaluation 
and management service(s) beyond the maximum required time of the primary procedure which has been 
selected using total time on the date of the primary service; each additional 15 minutes by the physician or 
qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 
99205, 99215, 99483 for office or other outpatient evaluation and management services). 
 
We find that CPT code G2212 is not supported in the medical record. Specifically this is an add-on code that was not billed with the required 99205, 99215, or 99483 primary procedure code. 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 pay for procedure code G2212 billed for July 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says a trial of analgesics and intra-articular steroids is required before alternatives can be 
considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the record does not show a failed trial of the plan 
preferred treatments, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment (37765). 
 
You asked the Plan to pre-approve the varicose vein treatment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
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 varicose vein treatment. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found it is not clear that 
the patient is having lifestyle limiting symptoms due to varicosities. The patient has very small superficial veins 
and has other coexisting factors including a history of hip replacement, knee pain, arthritis, and drug-induced 
insomnia.  
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 varicose vein treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a varicose vein treatment (37765).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation (A0428, A0425) provided on November 16, 
2022. 
 
You asked the Plan to pay for ambulance transportation. You say that the enrollee was discharged from one 
facility before this transport was provided, and was admitted to a new facility after arrival. Therefore, these 
services should be separately payable. The Plan denied your request. The Plan says that these services would be 
included in a facility payment. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no documentation to support that these 
services would be included in the payment to any facility. There is no evidence that the enrollee maintained 
inpatient status with one facility on the date in question or that the enrollee was transported to a different 
building within the same hospital/facility group. These services are not supported as being inpatient 
transportation. The Plan's denial is not substantiated, and these services should be separately payable based on 
the documentation provided. Therefore, we decided that the Plan has to pay for ambulance transportation 
(A0428, A0425) provided on November 16, 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 pay for the x-ray exam of the thoracolumbar junction, minimum of 2 
views (72080) provided on November 23, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray exam of the thoracolumbar junction, minimum of 2 views (72080) 
provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60 bottles of Boost Original Nutritional Drinks per 
month. 
 
  You asked the Plan to pre-approve 60 bottles of Boost per month. You say that you are underweight, and this 
drink was recommended to you by your primary care physician. You also say that you cannot afford to 
purchase the drinks on your own. The Plan denied your request. The Plan says the Boost Original Nutritional 
Drinks you requested are not an item listed in the OTC catalog. The Plan also says this request to use your 
OTC benefit to cover Boost Original Nutritional Drinks is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although Medicare does 
not pay for nutritional supplementation, the Plan offers a benefit that allows coverage for specific health and 
wellness products. Boost is not listed as a covered health and wellness product. Therefore, we decided that the 
Plan does not have to pre-approve 60 bottles of Boost Original Nutritional Drinks per month.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need this 
transportation to and from surgery. The Plan denied your request. The Plan says the requested trip exceeds the 
Plan's mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. The requested trip in this case is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile limit.