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

 
We decided that the Plan does not have to pay for ophthalmological services provided on May 27, 2022, by an 
OON provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says you must receive your care from a network 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 ophthalmological services provided on May 27, 
2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacroiliac (SI) fusion. 
 
You asked the Plan to pre-approve percutaneous SI fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous SI fusion. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested percutaneous sacroiliac 
(SI) fusion, in this case, is not medically reasonable or 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 percutaneous SI fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous sacroiliac (SI) fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee needs this hospital 
bed. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested hospital bed is not medically necessary. Our physician reviewer found it is not 
standard practice to manage a hip fracture with positioning not available with a standard bed. The submitted 
records do not document unusual positioning is 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment, methadone, (G2067) 
provided from July 3, 2022, to July 24, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that this claim was denied in error. The Plan 
denied your request. The Plan says documentation was not provided to show that the individual provider is 
Substance Abuse and Mental Health Services Administration certified to provide this service. 
 
The Plan must follow Medicare rules. Medicare rules say that opioid treatment programs (OTPs) must be 
certified by Substance Abuse and Mental Health Service Administration (SAMHSA) to furnish Medicare-
covered opioid use disorder (OUD) treatment services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the records do not support that the specific 
location of the facility in this case is certified by SAMHSA. Therefore, we decided that the Plan does not have 
to pay for the medication assisted treatment, methadone, (G2067) provided from July 3, 2022, to July 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 25, 2021, to 
September 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the emergency medical services and 
inpatient care provided to the enrollee were medically necessary. The Plan denied your request. The Plan says 
that the provided records do not support the criteria were met for inpatient hospitalization. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 25, 2021, to September 27, 2021.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on November 
25, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the provider 
is not recognized by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services 
provided on November 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2301) and 
supplies (A4239). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (E2301) and supplies (A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options (K0861) and accessories. 
 
You asked the Plan to pre-approve Group 3 PWC K0861. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not require multiple power options and thus does not meet 
criteria for a K0861 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 PWC with multiple power options 
(K0861) is only covered if certain 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 Group 3 PWC K0861. Our reviewer 
says that the enrollee does not meet criteria for a K0861 power wheelchair. Our physician reviewer found the 
records do not document that the enrollee has a musculoskeletal condition or the presence of a case or brace 
which prevents 90-degree flexion at the knee, or the enrollee has significant edema of the lower extremities that 
requires a power elevating leg rest. Records do not support that the enrollee is high-risk for skin breakdown, 
has a history of pressure ulcers, or has had skin flap surgery. Records do not support that the enrollee performs 
bladder self-catheterization or that the enrollee has increased muscle tone or spasticity to meet criteria for a 
power tilt/recline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 3 PWC K0861 have not been met. Because the base power wheelchair is 
not covered, all related accessories are also denied. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair (PWC) with multiple power options (K0861) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service August 28, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the records do 
not support the billed level of service. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
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 billed services. Our reviewer found that 
the enrollee has a history of hypothyroidism and hyperlipidemia who was evaluated for fatigue. The 
documentation did not support a medically appropriate history and/or examination and moderate level of 
medical decision making. We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99204 billed for date of service August 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 
(22513) provided September 30, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that procedure 22513 was medically necessary 
based on the attached supporting documentation. The Plan denied your request. The Plan says the clinical 
submitted does not include documentation to support all of the criteria required for Medicare. 
 
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 pay for the surgical procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows bone retropulsion into the spinal canal 
at T12 where the fracture is. This is a relative contraindication to kyphoplasty. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the percutaneous vertebral augmentation, including cavity creation (fracture reduction 
and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, 
unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic (22513) provided September 30, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided January 
14, 2022. 
 
You asked the Plan to pay for the emergency visit. You say that you disagree with the review and have 
prepared a detailed letter of your review. Please review and reconsider payment of the claim. The Plan denied 
your request. The Plan says the criteria was not met for CPT code 99284. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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 the emergency visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found for emergency department services 3 of 3 key components must be met or exceeded. In this case, the medical 
record supports a comprehensive detailed history, comprehensive detailed exam and low complexity medical 
decision making. There is a more appropriate code to report for service provided. 
 
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 emergency visit have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99284) provided January 14, 2022.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documentation does not support necessity for admission to an IRF and the complexity of the enrollee's nursing, rehabilitation, and medical needs (no complexity) does not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. While the enrollee 
may benefit from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can 
be provided in a lower intensity and alternate setting such as in a skilled nursing facility (SNF). 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device. 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is experimental. 
 
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 Motion G device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence that the MyoPro device will improve the long-term 
outcomes for this enrollee. 
 
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 Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has carbon dioxide retention. The 
Plan denied your request. The Plan says the enrollee has not failed BiPAP. 
 
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 ventilator. Our physician reviewer 
found that the enrollee was recently hospitalized with an acute exacerbation of COPD. An arterial blood gas 
(ABG) was consistent with acute on chronic hypercarbic respiratory failure. The enrollee was intolerant of 
BiPAP in the hospital. There is no ABG while stable to document chronic carbon dioxide (CO2) retention. If 
there is chronic CO2 retention, may benefit from BiPAP during sleep. However, Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. Therefore, a home ventilator is not 
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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 a home ventilator. You say that BiPAP flow capability is extremely limited. 
The Plan denied your request. The Plan says a BiPAP has features that will meet the enrollee's needs. 
 
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 physician 
reviewer found that the enrollee has COPD, sarcoidosis with mediastinal adenopathy and interstitial lung 
disease, pulmonary hypertension, and severe obesity. There are no pulmonary function tests to document the 
severity of the COPD.  An arterial blood gas (ABG) while acutely ill showed mild carbon dioxide (CO2) 
retention. There is no ABG while stable to document chronic CO2 retention. This enrollee may benefit from 
BiPAP during sleep. However, Medicare does not cover a home ventilator when used as BiPAP. Therefore, a 
home ventilator is not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.