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

 
We decided that the Plan has to pay for the anesthesia provided on November 11, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the provider information and medical records are 
included. You say that the documentation should be reviewed, and the claim reprocessed for payment. The Plan 
denied your request. The Plan says that anesthesia codes can only be reimbursed to anesthesia providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a valid rationale for why the rendering provider type 
is not appropriate for anesthesia services. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the anesthesia provided on November 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; whole body (78816). 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says the enrollee has exceeded the allowed limit of three scans. 
 
The Plan must follow Medicare rules. Medicare rules say that you are allowed three PET scans. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole 
body (78816). 
 
We looked at the file and Medicare rules. The records show that the enrollee had a PET scan on July 15, 2021, 
October 14, 2021, and February 1, 2022, therefore, the enrollee has exceeded the allowed amount of three 
scans per year. Therefore, we decided that the Plan does not have to pre-approve a positron emission 
tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and 
anatomical localization imaging; whole body (78816).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical components of the neuromonitoring services 
provided on August 25, 2021. 
 
You asked the Plan to pay for the technical components of the neuromonitoring services. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
payment for these services have been included in the facility benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and non-physician services are included in 
payment to the facility during an inpatient hospital stay. 
 
The technical components of these services include technician time and supplies. These are not separately paid 
and are included in facility payment. Therefore, we decided that the Plan does not have to pay for the technical 
components of the neuromonitoring services provided on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman procedure. 
 
You asked the Plan to pre-approve the Watchman procedure. You say that the records provided support the 
need for the requested procedure. The Plan denied your request. The Plan says the requested 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 Watchman procedure. Our reviewer 
says that the Watchman procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provider is requesting to implant an LAAC device in this enrollee who has an 
elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. There is no 
apparent contraindication to anticoagulation. As such, guidelines would not support the Watchman procedure 
in this setting or for the enrollee's clinical management. 
 
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 Watchman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Watchman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transluminal mechanical thrombectomy and/or 
infusion for thrombolysis (CPT code 36906) and transluminal balloon angioplasty (CPT code 36907) provided 
on December 28, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Our records indicate surgery procedure 36906 has a global surgery value of 010 on the CMS National 
Physician Fee Schedule (NPFS) Relative Value (RVU) File. This is a minor procedure that has a global surgery 
period of 10 days. Procedure 36906 billed on date of service December 28, 2021, is included within the global 
surgery package of procedure 36558 billed on date-of-service December 24, 2021. As the CPT code 36907 was 
billed without an appropriate primary code and not performed by the same practitioner on the same date of 
service; we find that Medicare rule for payment for CPT code 36907 has not been met. If the provider 
determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a 
submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis (CPT 
code 36906) and transluminal balloon angioplasty (CPT code 36907) provided on December 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diclofenac Gel 1%. 
 
You asked the Plan to pre-approve Diclofenac Gel 1%. You say that the medication is necessary. The Plan 
denied your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Diclofenac Gel 1%.  
 
 
 
 Benefits for Diclofenac Gel 1% may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre 2 sensor (CPT code K0553) provided on 
November 7, 2021. 
 
You asked the Plan to pay for the sensor. You say that you submitted medical documentation for review of 
medical necessity. The Plan denied your request. The Plan says they did not receive information to verify the 
sensor is necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the sensor. Our physician reviewer found the 
enrollee is not treated with three or more daily administrations of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion pump. The enrollee is using Levemir insulin twice daily. Records indicate the 
enrollee has been advised to use a sliding scale for their insulin but provided records do not clearly state that 
the enrollees insulin treatment regimen requires frequent adjustment by the enrollee on the basis of blood 
glucose monitoring (BGM) or CGM testing results. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have 
to pay for the FreeStyle Libre 2 sensor (CPT code K0553) provided on November 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on December 29, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services should be covered. 
The Plan denied your request. The Plan says the ambulance services were 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 the ambulance services. Our reviewer says 
that the ambulance services are not medically necessary. Our physician reviewer found the documentation 
supports that the enrollee could have safely been transported by any other means of transport. Therefore, the 
reviewer found that the ambulance services were 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and 
ground mileage (A0425) provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the modified barium swallow study (MBSS) provided in a 
mobile unit on November 29, 2021, billed with codes 92611, 74230, 72040, 70100, 70310, 71045, and 72240. 
 You asked the Plan to pay for the MBSS as billed. You say that this was correctly billed and provided in a 
fixed physician office on wheels. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MBSS are not shown to be medically effective 
when provided in a mobile setting. In addition, codes 70370, 70371 and 74230 describe a complete MBSS and 
should be billed only once per date of service. 
 
We looked at the file and Medicare rules. This claim billed each individual component of the swallow study as 
separate x-rays, in addition to the correct code 74230. This is not correctly billed according to the LCD/LCA. 
In addition, this MBSS was provided in a mobile unit, not an office setting. This is not covered per Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the MBSS as billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the modified barium swallow study 
(MBSS) provided in a mobile unit on November 29, 2021, billed with codes 92611, 74230, 72040, 70100, 
70310, 71045, and 72240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myopro powered upper extremity range of motion 
assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a Myopro powered upper extremity range of motion assist device. You say 
that the requested device is medically necessary. The Plan denied your request. The Plan says the requested 
service 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 a Myopro powered upper extremity 
range of motion assist device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested robotic orthosis is not 
proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after 
stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy 
including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if 
needed.  The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to 
improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on 
scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. 
The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the 
literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic 
arm function, or be safe for long term 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 a Myopro powered upper extremity range of motion assist device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Myopro powered upper extremity 
range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, 
sensors, all components and accessories, custom fabricated (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deep gum and root cleaning (D4341) in the lower right 
quadrant, upper right quadrant, and lower right quadrant. 
 
You asked the Plan to pre-approve the deep cleaning. You say that this service is medically necessary. The 
Plan denied your request. The Plan says you do not have enough teeth in these quadrants to meet the criteria for 
coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the deep 
cleaning when the services are medically necessary and reasonable.  
 
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 deep cleaning. Our reviewer says 
that the criteria for coverage was not met. Our physician reviewer found that the upper left and right quadrants 
have one remaining tooth, and the lower right quadrant has two remaining teeth. As there are an insufficient 
number of teeth in any one quadrant to satisfy the requirement of there being four or more involved teeth in a 
quadrant, a deep gum and root cleaning does not meet the Plan's criteria and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the deep cleaning have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a deep gum and root cleaning (D4341) in the lower right quadrant, upper right 
quadrant, and lower right quadrant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance (E0673) 
and a pneumatic compression device (E0675) provided on November 16, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the requested devices were issued 
to the enrollee for use during his surgery to help prevent PE/DVT. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 The Plan follows Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than 
the facility or hospital for services furnished to the beneficiary while an inpatient. The facility or hospital must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made between 
the facility and hospital and outside providers. 
 
The records show the enrollee used the equipment in the facility during and/or after surgery. Payment for this 
service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the 
Plan does not have to pay for a segmental gradient pressure pneumatic appliance (E0673) and a pneumatic 
compression device (E0675) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, and 81301) 
provided on November 4, 2021. 
 
You asked the Plan to pay for codes 81206, 81275, 81276, and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81275, 81276, and 81301) provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided from 
December 29, 2021, through December 31, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided do not meet Medicare 
criteria for coverage. 
 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were rendered by a licensed 
acupuncturist who was not under the supervision of a physician, physicians assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided from December 29, 2021, through December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture repairs provided on August 16, 2021. 
 
You asked the Plan to pay for denture repairs. You say that you didn't confirm with the provider that the 
provider was participating with your plan prior to receiving the services. The Plan denied your request. The 
Plan says the provider is out-of-network and it was determined these services can be received in-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, denture repairs are only covered when 
provided in-network. Therefore, we decided that the Plan does not have to pay for denture repairs provided on 
August 16, 2021.