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

 
We decided that the Plan does not have to pay for continued use of a continuous positive airway pressure 
device (CPAP) from August 23, 2022, to September 22, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says you did not meet the compliance requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that adherence to CPAP therapy is defined as use for 
4 or more hours per night on 70% of nights. 
 
The records show that CPAP was only used for 4 hours or more on 9% of nights. 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 continued use of a continuous positive airway pressure device (CPAP) from August 
23, 2022, to September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device billed for date of service 
June 17, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was issued to the 
patient for use during their surgery.  You stated that you do not receive payment from the facility. The Plan 
denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF, a hospital, or an ambulatory surgical 
center to be a home. Medicare rules also say that pneumatic compression devices that provide intermittent limb 
compression for the purpose of prevention of venous thromboembolism are excluded from coverage under the Medicare DME benefit. 
 
Records show that the pneumatic compression device was used in an ambulatory surgical center. Further, the 
records show that the pneumatic compression device at issue was provided for the prevention of venous 
thromboembolism during surgery.  Medicare does not cover this item for that purpose. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device billed for date of service June 17, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Hyalgan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope (69990). 
 
You asked the Plan to pre-approve an operating microscope. You say that the services are necessary. The Plan 
denied your request. The Plan says this service cannot be billed separately with the requested and approved 
type of surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement code (CPT 69990) for modifier -20 - 
microsurgical techniques requiring the use of operating microscopes may be paid separately only when 
submitted with specific CPT codes.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an operating microscope have not been met. Therefore, we decided that the Plan does not have to 
pre-approve microsurgical techniques, requiring use of operating microscope (69990).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 You asked the Plan to pre-approve the compression stockings. You say that your legs swell, and you are in pain 
without the compression stockings. The Plan denied your request. The Plan says compression stockings are 
only covered in the presence and for the treatment of an open wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the requested Minuteman procedure 
is medically necessary. The Plan denied your request. The Plan says the requested Minuteman procedure is 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 the Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not medically necessary. Our physician reviewer 
found the Minuteman procedure is experimental. More research is needed 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277). 
 
You asked the Plan to pre-approve HBO therapy. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the use of hyperbaric oxygen for this enrollee's clinical scenario is statutorily 
excluded from coverage by this Medicare NCD. 
 
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. The records show that the enrollee would like to receive the HBO 
therapy for a traumatic brain injury. Medicare provides a list of specific treatment that is covered for HBO 
therapy. The NCD has specific exclusionary language that indicates that if a condition is not listed under the 
"covered conditions" in the NCD, then they are excluded from coverage by Medicare. Based on this 
information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (99183, G0277).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 17, 2022 to 
February 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 17, 2022 to 
February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, lidocaine hcl for intravenous infusion, 10 mg 
provided to the enrollee on March 11, 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 Healthcare Common Procedure Coding System (HCPCS) code J2201 59 (15 Units) remains not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
modifier 59 would not be appropriate for J2001. The documentation does not support the use of J2001 as 
distinct and separate from procedures 62323 and 64430. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay for injection, lidocaine hcl for intravenous infusion, 10 mg provided to the enrollee on March 11, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not have documented skilled nursing or skilled therapy needs. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollee's 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet certain criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the imaging studies show bone retropulsion 
which is a 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code K0553 billed for date of service August 22, 
2022. 
 You asked the Plan to pay for procedure code K0553. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code K0553 is 1. The MAI value for this code is 3. You billed 5249 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code K0553 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code K0553 billed for date of service August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox, 600 units every three months. 
 
You asked the Plan to pre-approve Botox, 600 units every three months. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested Botox at 600 units every three months 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Botox, 600 units every three months. 
Our reviewer says that the documentation does not support that the requested Botox at 600 units every three 
months is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of left 
spastic hemiparesis. There is no documentation that meets criteria for Botox at 600 units every three months. 
As stated in Micromedex, "Maximum cumulative dosage of Botox should not exceed 400 units, in a three-
month interval when treating adult patients for one or more indications". Therefore, the enrollee does not meet 
criteria for the requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox, 600 units every three months have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Botox, 600 units every three months.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have documented skilled nursing or skilled therapy needs. You 
appear to be functioning at/near your baseline. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs can, as a practical matter, 
be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for approval of the requested CGM. 
 
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 you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on April 20, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that the 
enrollee met medical necessity for the transport and have submitted supporting medical records for review. The 
Plan denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found the transportation via ambulance from the hospital to a nursing home was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport.  Oxygen is used/administered via a portable tank/concentrator by laypersons. Transportation could have been 
provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 
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 ambulance service, basic life support, emergency transport have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency 
transport and ground mileage provided on April 20, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport 
provided on August 7, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the ambulance service was necessary to get the enrollee safely to a hospital because he is in a wheelchair and 
his other leg is amputated. The Plan denied your request. The Plan says that the ambulance transport was not 
medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance transport was medically necessary. Our physician 
reviewer found the enrollee did require the expertise of trained personnel and equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could not have been provided by other means 
without endangering the enrollee's condition. A prudent layperson would believe that immediate medical 
attention was required for a wheelchair-bound amputee, who possibly had an infection in his remaining leg. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have been met. 
Therefore, we decided that the Plan has to pay for ambulance service, basic life support, non-emergency 
transport provided on August 7, 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.