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

 
We decided that the Plan does not have to pay for procedure codes 31276, 31267, and 31254 billed for date of 
service August 30, 2022. 
 
You asked the Plan to pay for procedure codes 31276, 31267, and 31254. You say that you would like the plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 31276, 31267, and 31254 is 1. The MAI value for these codes is 2. You 
billed 2 units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 31276, 31267, and 31254 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 31276, 31267, and 31254 billed for date of service August 
30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that you would like this medically necessary 
therapy to be approved for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for coverage. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. Our reviewer also found that the criteria are not met as routine 
use of proton therapy for the post-operative radiotherapy for prostate cancer is not within accepted standards of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 99135. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99135 is considered bundled and not separately 
payable. 
 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 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on September 7, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are covered in the home setting when medically necessary for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic 
compression devices are not covered by Medicare when the place of service is an ambulatory surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The records also show that you billed with place of 
service 24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to 
be covered, it must be appropriate and be needed for use inside the home. The PCD's were billed for use 
outside of the home and is not separately payable. Therefore, we decided that the Plan does not have to pay for 
a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device 
(E0675) provided on September 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 16, 2021, 
to December 21, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J18.9, described as 
pneumonia, unspecified organism. We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that diagnosis code J18.9 is not supported by 
documentation. Our physician reviewer found the documentation indicates that the enrollee was an 88-year-old 
female with a history of skin cancer and breast cancer who was admitted to the hospital after a fall due to 
hypercalcemia. The chest x-ray performed demonstrated possible bronchitis versus pneumonia. In this case, the 
enrollee did not have any clinical, laboratory or radiographic signs of pneumonia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 16, 2021, to December 21, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 4, 2022, 
to April 18, 2022, as billed. 
 
You asked the Plan to pay for the inpatient services as billed. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the code that was 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 inpatient services as billed have 
been met. Specifically, no medical records were submitted for review despite multiple attempts by the Plan. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from April 
4, 2022, to April 18, 2022, as billed.
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. The Plan denied your request. The Plan says the records do not 
show the need for skilled rehabilitative services daily in an inpatient setting, services required can safely be 
received at a different setting, home with home health, in residential care, or home with close follow-up with 
your doctor. 
 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that sclerotherapy is covered when specific criteria 
are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found there is sufficient documentation that the 
enrollee has significant symptoms attributable to varicose veins. He has a long history of varicose vein 
treatments in the past with evidence of recanalization of portions of the great saphenous vein and associated 
varicosities. Satisfactory arterial perfusion to lower extremities bilaterally is documented as is the absence of 
deep vein thrombosis (DVT). As he has previously undergone multiple ablative procedures to the great 
saphenous veins, sclerotherapy to the residual refluxing remnants appears to be safe and reasonable. There is 
no documentation suggesting that the sclerotherapy is intended to treat near the saphenofemoral junction. There 
is sufficient documentation of symptoms persisting despite conservative treatment. The services are reasonable 
and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve sclerotherapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided August 2, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
August 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Barostim Neo system (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 Barostim Neo system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient 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 a Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Barostim Neo system (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the infrared therapy (92076) 
provided from May 6, 2022, to July 21, 2022. 
 
You asked the Plan to reimburse an additional amount for the infrared therapy. You say that you spent two 
weeks in bed with intense and unbearable pain. You say that you were forced to take regenerative therapies for 
relief. You say that you paid $1,800 out-of-pocket for these services. You also say that you were only 
reimbursed $63. The Plan denied your request. The Plan says additional payment cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met.  Therefore, we decided that the Plan does not have to 
reimburse an additional amount for the infrared therapy (92076) provided from May 6, 2022, to July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on August 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this was denied because the services were rendered 
by a non-participating provider. You had assumed all was ok as you had seen this provider in January 2022 and 
was not notified of any differences in service coverage when you made your surgery checkup. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 outpatient office visit provided on August 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted case management services described by code 
T1017. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has moderate recurrent major 
depression. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
The requested services are described by procedure code T1017. This code has a Status Indicator of I on the 
Physician Fee Schedule. This means that procedure code T1017 is not valid for Medicare purposes. 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 targeted case management services described by code 
T1017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair with multiple power options 
(K0861). 
 You asked the Plan to pre-approve the power wheelchair. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not have 
a medical need for a Group 3 power wheelchair with the requested power option features. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee has a neurologic disorder with functional deficits. The 
criteria for a power wheelchair are met. The documentation does not indicate that the enrollee has any pressure 
injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or recline. 
Although the enrollee meets criteria for a power wheelchair, they do not require the specifically requested 
power wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Group 3 power wheelchair with multiple power options (K0861).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Herceptin (trastuzumab). 
 
You asked the Plan to pre-approve Herceptin (trastuzumab). You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the requested 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 Herceptin (trastuzumab). Our reviewer 
says that the documentation supports that the requested drug is medically necessary. Our physician reviewer 
found the enrollee has salivary duct cancer III stage. The documentation shows that the use of the requested 
drug is supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services-approved medical journal. The documentation supports that the requested drug 
is safe and effective and otherwise reasonable and necessary for this enrollee. Therefore, the enrollee meets 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herceptin (trastuzumab) have been met. Therefore, we decided that the Plan has 
to pre-approve Herceptin (trastuzumab).  
 
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.