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

 
We decided that the Plan has to pre-approve an Ability Drive eye gaze control system (K0108). 
 
You asked the Plan to pre-approve the Ability Drive eye gaze control system. You say that this device is 
medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the Ability Drive eye gaze control 
system. Our reviewer says that the requested services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of Amyotrophic Lateral Sclerosis. The enrollee 
cannot use a sip and puff control. Therefore, he requires the eye gaze control system to operate the power 
wheelchair and is medically appropriate given his condition. There is not an alternative drive control system 
that the patient can use and it is not considered experimental or investigational since there is medical literature 
supporting its use. 
 
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 Ability Drive eye gaze control system have been met. Therefore, we decided 
that the Plan has to pre-approve an Ability Drive eye gaze control system (K0108).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 16, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on June 3, 2022. 
 You asked the Plan to pay for the air ambulance services. You say that the medical records provided support 
the need for the air ambulance transport. The Plan denied your request. The Plan says the appeal does not 
support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance transport was not medically necessary. Our physician reviewer found the record 
indicates that the enrollee was transported between acute care facilities for a higher level of care. The records 
also indicate that the enrollee was not transported to the nearest facility  with the capability  of caring 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 the air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on June 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 15271 billed for date of service November 21, 2022. 
 
You asked the Plan to pay for code 15271. You say that this code should not be bundled into the payment for 
code Q4229. The Plan denied your request. The Plan says code 15271 occurred within 10 days of you billing 
code 17000, so it is included in the global surgical package for that code. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare designates a postoperative period for 
all surgical procedures.  That period can be 0, 10, or 90 days. During the global period, certain services related 
to the surgery are considered part of the surgery itself and not separately payable.  This is called the global 
surgical package.  The global surgical package includes the following items and services: preoperative visits, 
intra-operative services, complications following surgery, postoperative visits, postsurgical pain management, supplies, and other miscellaneous services related to the surgery. 
 
In this case, you billed code 17000 for date of service November 14, 2022. This procedure has a 10-day 
postoperative period.  This means that follow-up and related services occurring within this period are not 
separately payable.  Based on the medical records, code 15271 is clearly related to the procedure on November 
14, 2022.  As a result, this code is considered part of the global surgical package and no additional payment is 
made.  It should be noted that the Plan did not deny code 15271 because it was packaged with code Q4229.  It 
was denied because it is part of the global package for code 17000. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 15271 have not been met. Therefore, we decided that the Plan does not have to pay for code 
15271 billed for date of service November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a quad or three-prong cane (E0105) provided on July 1, 
2022. 
 
You asked the Plan to pay for a quad or three-prong cane. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
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 a valid proof of delivery for the supplies provided in this case. The documents 
provided as proof of delivery are for another date of service. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a quad or three-prong cane (E0105) provided on July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick Urine Collection System. 
 
You asked the Plan to pre-approve a Purewick Urine Collection System. You say that you get urinary tract 
infections (UTIs) and have incontinence. The Plan denied your request. The Plan says the notes do not show 
that a standard urinary catheter will not meet your needs. 
 
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 Purewick Urine Collection System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that a special urinary catheter (device used to collect urine) may be 
approved only when it has been shown that a standard urinary catheter, will not meet your needs. In this case, 
the notes indicate that you have urinary incontinence. The notes do not show that a standard urinary catheter 
will not meet your needs. 
 
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 Purewick Urine Collection System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Purewick Urine Collection System.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug is not medically 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 the medication. Our physician reviewer 
found there is no documentation of a trial and failure or contraindication of at least 3 months of conservative 
therapy, including: 
 
    Non-pharmacologic therapy (e.g., physical therapy, exercise, weight management, self-management 
programs, knee brace, cane) 
    Pharmacologic therapy (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (oral, topical), 
topical capsaicin) 
 
Intra-articular injections with hyaluronic acid (in this case, Euflexxa) are recommended as a possible option for 
severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments. 
In this case, the enrollee has not failed at least three months of conservative therapy such as, anti-inflammatory 
medications and physical therapy. 
 
The documentation does not support that Euflexxa is medically reasonable or necessary 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. As such, you strongly disagree with the decision. The Plan denied your 
request. The Plan says the Intercept procedure is denied as investigational and therefore 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental. More research is needed. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral water vapor thermal therapy (53854). 
 
You asked the Plan to pre-approve the water vapor therapy. You say that this request is medically necessary, 
and you are appealing the denial of water treatment, The Plan denied your request. The Plan says no records 
was provided that show that the enrollee meets the rules for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the water vapor therapy have been met. The records show that the Plan made several attempts to obtain needed medical records from the enrollee 
without success. Therefore, we decided that the Plan does not have to pre-approve the transurethral water vapor 
thermal therapy (53854).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durolane (J7318). 
 You asked the Plan to pre-approve Durolane. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have 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 Durolane. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc, Synvisc/Synvisc-One and 
Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not 
outline contraindications or reasons these medications were not considered or why 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Durolane (J7318).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the liposculpture (Sculptra, liposuction) (15877). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has previously had good 
results with Sculptra. Please facilitate coverage for this treatment. The Plan denied your request. The Plan says 
the requested service is excluded from coverage.  
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.  Medicare rules say that for Medicare to consider coverage and payment for any item or service, the 
information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked the file, and Medicare rules. The records show that the Plan attempted to obtain medical records 
from the requesting provider without success. 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 pre-
approve the liposculpture (Sculptra, liposuction) (15877).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, left 
and right (E0673 x 2) and pneumatic compression device (E0675) provided on September 22, 2022. 
 You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill according to Medicare rules. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Pneumatic compression devices are 
covered in the home setting when medically necessary for the treatment of lymphedema and/ or for the 
treatment of chronic venous insufficiency with venous stasis ulcers. Pneumatic compression devices are not 
covered by Medicare when the place of service is an ambulatory surgical center. The provider billed with Place 
of Service 24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment 
to be covered, it must be appropriate and be needed for use inside the home. A home may be a dwelling, an 
apartment, a relative's home, a home for the aged, or some other type of institution. Medicare does not consider 
an ambulatory surgical center a home. The pneumatic compression devices (E0673 and/or E0675) were billed 
for use outside of the home and is not separately payable. Therefore, we decided that the Plan does not have to 
pay for the segmental gradient pressure pneumatic appliance, left and right (E0673 x 2) and pneumatic 
compression device (E0675) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that the services are medically necessary. The Plan denied 
your request. The Plan says multiple attempts were made to obtain the medical records, but additional 
supporting documentation was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. Medical 
records were not provided. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you received a letter saying you were denied 
for durable medical equipment. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system. 
 
You asked the Plan to pre-approve a personal emergency response system. You say that your dad needs this 
service as he is not able to have 24-hour nurse care. You say that your dad had fallen and hurt himself, thus 
having to be hospitalized and in a skilled nursing facility and you are afraid that he will fall again, and feel he 
needs to be monitored. The Plan denied your request. The Plan says Medicare will not pay for precautionary 
equipment or self-help equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that Telephone Alert Systems are to be denied. These 
are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a personal emergency response system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a personal emergency response system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and psychotherapy provided on  
December 12, 2022. 
 
You asked the Plan to pay for the office visit and psychotherapy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and psychotherapy provided on  
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services (code 99232) provided on 
May 4, 2022. 
 
You asked the Plan to pay for subsequent hospital care services. The Plan denied your request. The Plan says 
we have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of subsequent hospital care services have 
been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care services  
(code 99232) provided on May 4, 2022.