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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has had multiple recent 
hospitalizations for acute respiratory failure. She has a diagnosis of chronic obstructive pulmonary disease 
(COPD), end-stage renal disease on dialysis, obstructive sleep apnea (OSA), and Crohn's disease. There is an 
arterial blood gas (ABG) in the record from January 20, 2023 that was consistent with mild acute on chronic 
carbon dioxide (CO2) retention. There is no ABG done while stable to document chronic CO2 retention. The criteria for coverage are not met and the ventilator is 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 a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve the injections. You say that you have an extensive medical history. You also 
say that without the injections, your morphine will need to be increased. The Plan denied your request. The 
Plan says that the injections are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain criteria have been 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 the injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that chiropractic care or physical therapy has been completed for your lower back. The reviewer also 
found that there was no imaging documentation provided. Therefore, the reviewer found that the injections are 
not medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (ESIs) (64483, 64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214, 99215) with a 
cardiothoracic surgeon to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must use network providers to get 
health care and services when there are network providers available. There are participating providers available 
in the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99214, 99215) with a cardiothoracic surgeon to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spine surgery (Level L 3-4), bone growth stimulator, 
and back brace. 
 
You asked the Plan to pre-approve a spine surgery (Level L 3-4), bone growth stimulator, and back brace. You 
say that the services are medically necessary. 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 a spine surgery (Level L 3-4), bone 
growth stimulator, and back brace. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not 
evident regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care 
measures. There is no documentation of any injections having been tried and failed. Moreover, dynamic 
flexion/extension films did not demonstrate movement (instability) at the requested surgical level. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. The associated requests for a postoperative bone growth stimulator and a back brace would 
not be supported, as the procedure is not supported. 
 
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 spine surgery (Level L 3-4), bone growth stimulator, and back brace have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a spine surgery (Level L 3-4), bone 
growth stimulator, and back brace.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the ear impression (V5275) provided on 
September 6, 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 payable as it 
was received 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.  
 
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 this service have not been met. Specifically, the Plans contract states that hearing aids or related 
services received from an out-of-network provider are not covered. The service at issue in this case was 
rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the ear impression (V5275) provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads; with 
interpretation and report rendered on June 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation did not support the charges. 
 
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 93000 is "electrocardiogram, routine ECG with at least 
12 leads; with interpretation and report rendered on June 6, 2022." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
support the technical components of an ECG. There is a more appropriate code to report for professional 
component to report of ECG. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for electrocardiogram, routine ECG with at least 12 leads; with interpretation and report rendered 
on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 24, 2022, 
to October 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says this inpatient admission was not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 24, 2022, to October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
 
 
 
 You asked the Plan to pre-approve a CPAP device. You say that you are in compliance with your doctors 
orders for usage of the CPAP machine. You are asthmatic, you have high blood pressure, you are diabetic, and 
financially, you would not be able to afford the device on your own. You need the machine to breath at night 
when you are sleeping. The Plan denied your request. The Plan says you are not compliant with using the 
CPAP. There is no evidence that you are adhering to CPAP therapy. You have not used the device at least 70% 
of the time for 4 or more hours per night during a consecutive 30-day period. A CPAP can only be approved 
for enrollees who are compliant with using it. 
 
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 CPAP device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have asthma, and presumably, obstructive sleep apnea.  You have been prescribed CPAP, 
and a compliance report covering January 11 to February 9, 2023, shows the device was used at least 4 hours 
per night for only 7% of nights. This is not enough use to be effective and does not meet minimum Medicare 
requirements of 70% of nights with at least 4 hours per night. There is no record of a follow-up visit to assess 
effectiveness and compliance. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips. 
 
You asked the Plan to pre-approve Accu-Chek test strips. You say that the enrollee requires the Accu-Chek test 
strips and lancets because they are the only one who work with the enrollee's pump. The Plan denied your 
request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-Chek test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test 
strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo procedure. 
 
You asked the Plan to pre-approve Barostim Neo. You say that the enrollee's condition is progressively 
worsening. The Plan denied your request. The Plan says studies have not proven that this is helpful for the 
enrollee's condition. 
 
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 Barostim Neo. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining the long-term 
outcomes to establish the clinical value of Barostim Neo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0483) provided on May 12, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says that this service is not supported in the medical 
record as requested with the code reported. 
 
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 G0483 is drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records support that drugs 
from 23 classes were tested in this case. The order form indicates that every category was selected for testing, 
and although the form categorizes the listed drugs in 14 categories, the categories on the form do not 
correspond to the defined drug classes. The requested drugs match the drugs tested. Based on this information, 
we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing (G0483) provided on May 12, 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 ultrasound services provided on October 10, 2022. 
 
You asked the Plan to pay for ultrasound services provided. 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 services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76937-26 is Ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real time ultrasound visualization of vascular needle entry, with permanent recording and reporting. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for ultrasound services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical records provided do not 
include sufficient documentation to validate the billed code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasound services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for ultrasound services provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223. 
 
You asked the Plan to pay for code 99223. You say that this code was appropriate and should be paid. The Plan 
denied your request. The Plan says code 99223 for date of service October 24, 2022, is not supported by the 
medical record. The records do not support a comprehensive history. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; 
a comprehensive exam; and medical decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the Cardiology Attending Addendum states the 
following: "I have seen and examined the patient with the PA. I personally reviewed all elements of the history 
and repeated the physical exam as appropriate. I have also reviewed the labs, imaging, and EKG. Pertinent physical exam findings: elevated JVP with prominent v waves. Pertinent studies: echo personally reviewed and 
showed severe TR. For full plan, please see attached note. In summary, we will continue medical therapy for 
angina and increase her anti-anginal therapy. Agree with blood transition and work- up of anemia which is 
probably her pre-disposing factor for presentation. Will increase intensity of statin. May need significant 
diuresis, and likely would benefit from tricuspid valve repair in the long term." Based on this, the medical 
records did not support a comprehensive history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 3, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says these codes are part of the primary procedure. 
 
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 75774-59 and 75736-26-59 (x2) is a column II code to column I code 
37243; however, 75774-59 and 75736-26-59 (x2) was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found per code description of 37243, it is 
inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance 
necessary to complete the intervention; for tumors, organ ischemia, or infarction. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you were approved 
for a hospital bed and the vendor informed you that you would need the requested mattress due to your weight. 
The Plan denied your request. The Plan says you do not meet Medicare criteria for approval of the requested 
mattress. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that the requested mattress is covered if you meet 
certain criteria. The records do not show that you have more than one stage II pressure ulcer or that you meet 
the other conditions mentioned above. Based on this information, we decided that Medicare rules for coverage 
of a powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure-reducing air mattress (E0277).