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

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided on March 3, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the enrollee was ordered the 
LifeVest by the cardiologist to protect the enrollee form sudden cardiac death. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 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 the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided on March 3, 2022, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization (37220, 37221, 37224, 
37225, 37226, 37227, 37228, 37229, 37230). 
 
You asked the Plan to pre-approve percutaneous revascularization. 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 PTA is covered when used under certain conditions. 
 
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 revascularization. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you have evidence of 
lower extremity arterial disease, but the evidence does not confirm the presence of severe arterial stenosis, nor 
evidence that the claudication symptoms are of sufficient severity that they interfere with activities of daily 
living. Moreover, the records do not show that guideline-directed medical therapy, such as  a program of 
structured exercise, has been carried out. As such, guidelines for peripheral revascularization are not met. In 
summary, there is insufficient documentation to support the medical necessity for peripheral revascularization 
in your 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 percutaneous revascularization have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous revascularization (37220, 37221, 37224, 37225, 37226, 
37227, 37228, 37229, 37230).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Quviviq 25MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Quviviq tablet is a self-administered drug and the medication does not fall under 
Part B 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 Quviviq 25MG tablet.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion (99205) to be provided by an out-of-
network provider. 
 You asked the Plan to pre-approve the second opinion. You say that you are being re-directed to another 
provider that is eight (8) hours away as opposed to the provider that you want to see which is four (4) hours 
away. The Plan denied your request. The Plan says these services can be provided at our preferred tertiary care 
center of excellence. The Plan states the Travel Benefit is established to offset the cost of travel for patients and 
their support person family members when Utilization Management provides and/or covered person, as an 
option for tertiary care (evaluation and or treatment), authorization to receive treatment from the Plan's 
facilities. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the second opinion (99205) to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77063 and 77067 billed for date of service 
July 22, 2022. 
 
You asked the Plan to pay for procedure codes 77063 and 77067. You say that you disagree with the denial. 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT codes 77063 and 77067 is 1. The MAI value for these codes is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 77063 and 77067 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 77063 and 77067 billed for date of service July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. 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 reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-
titration (AE) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not document enrollee compliance with use of the requested 
device as required by the LCD.  
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 (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 11720. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 11720 is bundled into payment for 
code 11719. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11720 
is a column II code to column I code 11719. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11720 billed for date of service July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (99213) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that other in-network providers are not 
accepting new patients right now or cannot see new patients until October. The Plan denied your request. The 
Plan says they gave you a list of primary care physicians are accepting new patients at this time and have 
availability approximately within the next eight (8) weeks. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services (99213) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on May 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99205 is not supported. 
 
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 99205 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 high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen by a provider of the same taxonomy from the same physician group within three years of the 
date of service at issue; therefore, a new patient office visit does not apply. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit rendered on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99000 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 99000. You say that you are on a limited income and any extra, 
added, unexpected expense is difficult to manage with your budget. The Plan denied your request. The Plan 
says procedure code 99000 is considered bundled and not separately payable. 
 
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 99000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99000 billed for date of service August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025), bifocal lenses (V2200), and 
scratch resistant coating (V2760) provided on May 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyewear. You say that the treating provider is in-network. You also say that 
this is for eyeglasses, and not for an eye doctor. The Plan denied your request. The Plan says there is no 
coverage for this eyewear because it was rendered by an OON provider, and there is no coverage when services 
are rendered by an OON 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. 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 
the deluxe frames (V2025), bifocal lenses (V2200), and scratch resistant coating (V2760) provided on May 16, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided August 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies,. You say that the claim denied for 
misrepresentation of service or diagnosis. A4595 is an accepted procedure code according to the Plan's durable 
medical equipment reference List (NCD 280.1). The Plan denied your request. The Plan says evidence of 
misrepresentation. 
 
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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider's 
office indicated on the claim form. The office confirmed that there is no order on file for this enrollee. 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 the electrical stimulator supplies, 2 lead, per 
month, (e.g., TENS, NMES) (A4595) provided August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 85025) provided on July 22, 
2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says these services are included in the payment to the Skilled 
Nursing Facility and are not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that when an enrollee is in a Part A covered SNF 
stay, payment for laboratory services furnished to this enrollee is made under the SNF PPS.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record shows that the enrollee in this case 
was admitted to a Part A covered SNF stay on the date in question. Therefore, we decided that the Plan does 
not have to pay for laboratory services (80048, 85025) provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kidney transplant (50360) with Piedmont Hospital. 
 
You asked the Plan to pre-approve a kidney transplant. 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 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 kidney transplant. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee must be cancer free for 
three to five years and cleared by oncology evaluation before a kidney transplant may be approved. 
 
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 kidney transplant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a kidney transplant (50360) with Piedmont Hospital.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57260 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code 57260. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 57260 is bundled into payment for code 52000. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 57260 
is a column II code to column I code 52000 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 57260 billed for date of service July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 11042 for August 30, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules state that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 11042 was related to and billed within 90 days of 
major surgical procedure 15738 billed on June 23, 2022. Payment for code 11042 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the surgical services billed with 
code 11042 for August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say you are requesting reconsideration of a 
LTACH services for the enrollee due to surgical aftercare following surgery. The Plan denied your request. The 
Plan says when ready to leave the hospital, the enrollee may safely receive this care in another setting, such as 
a Skilled Nursing Facility (SNF) or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LTACH would not be clinically advantageous for the enrollee at this time. 
Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98941 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 98941. You say that you disagree with the denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 98941 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 98941 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 98941 billed for date of service August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on August 27, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, this service was reported on 
the same day as a minor surgical procedure (code 10061). This means that payment for this code is included in 
the payment for the surgical code billed on this date of service. Based on this information, we decided that 
Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on August 
27, 2022.