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

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injections. You say that the injections are medically necessary for 
your diagnosis. The Plan denied your request. The Plan says the request is denied based on lack of medical 
necessity due to not meeting Medicare criteria for the procedure. 
 
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 facet joint injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found your MRI showed that there is multi-level neural foraminal stenosis with potential 
impingement of the bilateral L3 nerve roots and impingement of the left L4 nerve root. You also have 
anterolisthesis of L3 on L4 and L5 on S1. You, therefore, have multiple non-facet pathology on advanced 
imaging that could explain the source of your pain. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee is established with this provider and 
neither the enrollee nor provider were aware that a prior authorization would be needed for the services at 
issue. The Plan denied your request. The Plan says no prior authorization was obtained for the services 
rendered to the enrollee. The Plan says the rendering provider is out-of-network and no referring provider is 
involved with the services received. 
 
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 an office visit provided on May 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on April 27, 2022. 
 
You asked the Plan to pay for the shoulder orthosis. The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. While the case file includes two x-rays showing degenerative joint disease, there was no progress 
note including a physical exam of the shoulder, or quantifying pain level, or range of motion to support that a 
brace would be needed in this case. Therefore, we decided that the Plan does not have to pay for the shoulder 
orthosis provided on April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
December 14, 2021.  
You asked the Plan to pay for procedure codes 64493 and 64494. You say that you disagree with the Plan's 
denial. 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 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 
units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 64493 and 64494 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64493 and 64494 billed for date of service December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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 portable ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease, although there are no 
pulmonary function tests to confirm, and to assess severity. There is no documentation of chronic carbon 
dioxide retention, on an arterial blood gas (ABG) done while stable. You had a venous blood gas during a 
hospital admission in April, that showed a normal partial pressure of carbon dioxide in venous blood.  Medicare does not cover a home ventilator when used as bi-level positive airway pressure. Therefore, you do 
not meet criteria for the requested device. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says ventilators used to provide CPAP or bi-level 
PAP therapy will be denied as not reasonable and necessary. The requested device does not meet criteria for 
coverage. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, but there are no pulmonary function tests to confirm and to assess severity. An ABG in May, when the 
enrollee was admitted with acute mental status changes, was consistent with acute hypercarbic respiratory 
failure. There is no documentation of chronic CO2 retention with an ABG as an outpatient while stable. If the 
enrollee does have chronic CO2 retention, he may benefit from BiPAP with AVAPS during sleep. Medicare 
does not cover a home ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable 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 VAPS mode with 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
severe obesity. An ABG is consistent with chronic CO2 retention. The enrollee may benefit from BiPAP with 
AVAPS during sleep. This has not been tried. Medicare does not cover a home ventilator when used as BiPAP. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation. 
 
You asked the Plan to pre-approve a consultation. You say that you will be seen at any facility besides the one 
you have been assigned to, due to negative experiences. The Plan denied your request. The Plan says the 
enrollee's care can be provided by a community-level specialist and does not require tertiary care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 preapprove a consultation. Our reviewer says that 
the requested tertiary level of care is not medically reasonable or necessary. Our physician reviewer found that 
the Plan has shown that they have non-tertiary level of care providers who meet the standards of care required 
for treatment of your 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 a consultation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a consultation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the additional active wound care management debridement 
sessions requested on July 14, 2022. 
 
You asked the Plan to pre-approve the additional debridement sessions. You say that this is medically 
necessary wound care. The Plan denied your request. The Plan says that the documentation does not support 
this treatment. 
 
The Plan follows Medicare rules. Medicare rules say that active wound management debridement is indicated 
whenever necrotic tissue as well as cellular or proteinaceous debris is present on an open wound in order to 
keep the wound in an active state of healing.  
 
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 additional debridement sessions. 
Our reviewer says that though the documentation provided is limited, it does appear that additional 
debridement is indicated as described by the LCD. Our physician reviewer found the record indicates that the 
enrollee underwent a first metatarsophalangeal arthrodesis. The records indicate that the enrollee has sustained 
wound dehiscence. The progress note advises that there is adherent necrotic tissue at the wound edge. The 
necrotic tissue was debrided during this visit. It is also noted that the patient underwent, under aseptic 
technique, debridement of left foot adherent eschar tissue. This information supports that additional 
debridement was necessary at the time it was requested and denied. 
 
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 additional debridement sessions have been met. Therefore, we decided that 
the Plan has to pre-approve the additional active wound care management debridement sessions requested on 
July 14, 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: Favorable

 
We decided that the Plan has to pay for an office visit for evaluation and management of a new patient (99205) 
billed for date of service January 6, 2022. 
 
You asked the Plan to pay for a new-patient office visit. You say that the service at issue was billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. In this case, the Plan has denied a new-patient office visit because the enrollee 
visited another physician at the same practice within the past 3 years. The Plan indicates both physicians have 
the same specialty. Consequently, the enrollee cannot be billed as a new patient for the later date of service. 
However, Medicare records indicate the physicians at issue have different and distinct specialties. Billing the 
services at issue as a new-patient office visit is reasonable. The Plan has not provided any other possible 
rationales for denial. 
 
It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial rationale provided 
has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for an 
office visit for evaluation and management of a new patient (99205) billed for date of service January 6, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest; single view provided on 
May 11, 2020. 
 
You asked the Plan to pay for a radiologic examination, chest; single view. The Plan denied your request. The 
Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the 
date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a radiologic examination, chest; single view was not filed until 
April 21, 2022. This means that more than one calendar year from the date of service had passed before a claim 
was filed. Therefore, we decided that the Plan does not have to pay for a radiologic examination, chest; single 
view provided on May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve Farxiga. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga.  
 
 
 
 
 Benefits for Farxiga 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on March 21, 2022, to May 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you have been seeing the provider and you 
would like the plan to pay for services. The Plan denied your request. The Plan says the enrollee was educated 
prior to attending the visits in question with non-contracting provider. 
 
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 services provided on March 21, 2022, 
to May 3, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on March 1, 2021, to 
March 31, 2021. 
 
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 claim is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare Allowed Amount for this service. A Medicare provider should accept the Medicare Allowed Amount 
as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered on March 1, 2021, to March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found at the time of admission, it was reasonable for the treating physician to believe that 
two midnights of care would be needed for this enrollee with pneumonia in the setting of underlying alph-1 
antitrypsin deficiency. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital 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 pay for procedure codes  billed for date of service March 8, 2022. 
 
You asked the Plan to pay for procedure codes . You say that you disagree with the denial. 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 code 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 units 
each of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of procedure codes  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes  billed for date of service March 8, 2022.