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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided from 
December 30, 2021, to January 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that compression therapy aids in 
treatment of post-operative lymphedema that will be present after the surgical procedure and can accelerate the 
post-operative healing process. You say that the services were medically necessary, and the claim should be 
paid in full. The Plan denied your request. The Plan says the use of the pneumatic compression device in which 
it was ordered is not a covered. 
 
  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 (E0676) provided from December 30, 2021, to January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says the code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 22, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services 
cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the CPT codes at issue were billed with a -91 modifier. The records provided do not show that the 
testing was performed more than one once the date of service at issue. The codes were not billed with an 
appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage 
of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found current evidence-based medical 
guidelines and peer-reviewed literature do not fully support the Vertiflex Superion spacer over the gold 
standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollees medical condition. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
October 30, 2021. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. The Plan denied your request. The Plan says 
the codes are 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 codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99100 and 99140 billed for date of service October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on May 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you do not feel it is unreasonable to request 
reimbursement for your cost of $1,399.99. The Plan denied your request. The Plan says you obtained the 
hearing aids through an OON provider, and there is no record of a prior authorization being on file. 
 
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 you use a doctor in the Plan's hearing network. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids provided on May 6, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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 this beneficiary does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 240 One Touch Verio Test strips for a 30-day period. 
 
You asked the Plan to pre-approve 240 One Touch Verio Test strips for a 30-day period. You say that the 
records provided support the need for the number of test strips being requested. The Plan denied your request. 
The Plan says no information was provided as to why testing needs to be done 8 times per day. The Plan says 
that the request exceeds the quantity limitation. 
 
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 240 One Touch Verio Test strips for a 
30-day period. Our reviewer says that 240 One Touch Verio Test strips for a 30-day period are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the 
enrollee has diabetes.  The record provided does not indicate that the blood sugar is to be checked eight times 
daily. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 240 One Touch Verio Test strips for a 30-day period have not been met. Therefore, we decided that the Plan does not have to pre-approve 240 One Touch Verio Test strips for a 30-day 
period.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical spinal fusion. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not show that 
you have clinical nerve root dysfunction or severe spinal cord compression (myelopathy). The physical 
examination does not support the need for the requested fusion surgery. The services are not reasonable or 
medically necessary. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical spinal fusion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The 
Plan denied your request. The Plan says you had had stopped smoking more than 15 years ago. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that you stopped smoking in 2002, which is more than 15 years ago.. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, a wheelchair ramp (K0108). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you are wheelchair bound and need access 
to be mobile with entering and exiting your home. The Plan denied your request. The Plan says your request is 
not a covered benefit because these items are convenience items and do not serve a medical purpose. 
 
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 wheelchair accessory, a wheelchair ramp (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 25, 2020. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro robotic brace. 
 
You asked the Plan to pre-approve a MyoPro robotic brace. You say that the MyoPro is a covered device 
within the DME benefit category under Original Medicare. Therefore, the MyoPro cannot be considered 
experimental and/or investigational. The Plan denied your request. The Plan says the requested brace is not a 
covered benefit with the Plan. 
 
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 MyoPro robotic brace. 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 documentation that the MyoPro robotic brace at issue in this case meets 
all Medicare criteria per Social Security Act, Section 1862(a)1(A). Current clinical guidelines designate robotic 
therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" 
with unproven benefit in the home environment. 
 
 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 MyoPro robotic brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro robotic brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that you are receiving chemotherapy and have 
already exhausted your transportation benefit limit. The Plan denied your request. The Plan says you have used 
sixty (60) of the allowed sixty trips, and an additional sixty (60) trips would exceed your benefit 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 a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96365 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee cannot be seen until the claim is 
processed. The Plan denied your request. The Plan says the codes denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 96365 is a column II code to column I code 79101. This code has not 
been billed with an appropriate modifier to bypass the edit. We find that code 96365 is an add-on code. 
Because the primary code, 96365 is not covered, the add-on code is also not covered. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 96365 billed for date of service March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode without Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that you were 
successfully treated with AVAPS. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. You could be treated with a BiPAP 
machine with AVAPS capability. The plan has indicated coverage for such a device is available upon request. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the iTind procedure and cystourethroscopy services. 
 
You asked the Plan to pre-approve the iTind procedure and cystourethroscopy services. You say that the iTind 
procedure does not cause any of the side effects associated with prescription medications, and none of the risks 
to sexual function and urinary incontinence occur as are commonly a result of major surgery. You say that, 
unlike other minimally invasive surgical benign prostatic hyperplasia procedures, the iTind involves no heating 
or removal of prostate tissue and is not a permanent implant. You say that there is significant published 
evidence that demonstrates durable effectiveness and safety. The Plan denied your request. The Plan says the 
requested treatment is experimental and 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 the iTind procedure and 
cystourethroscopy services. Our reviewer says that the iTind procedure and cystourethroscopy services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found further studies are 
needed to evaluate the durability of iTind outcomes over a longer follow-up, to better define the indications of 
this approach, and to demonstrate the advantages of second-generation device over the first device. ITind is not recommended in the most recent American Urological Association (AUA) Guidelines regarding treatment of 
benign prostatic hyperplasia (BPH.) 
 
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 iTind procedure and cystourethroscopy services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the iTind procedure and cystourethroscopy 
services.
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 the enrollee does not meet the medical criteria for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. Our 
physician reviewer found the enrollee has had a functional decline from his baseline level of function, and would likely benefit from therapy, but he does not require the intensity of therapies provided on acute inpatient 
rehabilitation. 
 
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.