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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's respiratory failure has 
progressed to a point where the use of NIV is required during both day and night. It is imperative that the 
device has alarms and battery as backup, without these functions something like power failure in the home 
would put the enrollee's life in danger. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show that the requested device is to be used in a bi-level PAP mode, which can 
be provided by another device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, although 
there are no pulmonary function tests to assess severity. The enrollee was recently hospitalized with ABGs 
consistent with acute on chronic hypercarbic respiratory failure, possibly related to pneumonia and/or 
pulmonary edema, and UTI. There is no ABG done while stable to confirm chronic CO2 retention. If the 
enrollee does have chronic CO2 retention, she may benefit from BiPAP with AVAPS during sleep as an 
outpatient. This has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on the lower leg (below knee) 
(code 01470) provided on March 6, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the lower leg (below knee). The Plan denied your 
request. The Plan says traditional Medicare is responsible for payment of these services through the end of the 
month. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on March 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia for 
procedures on the lower leg (below knee) (code 01470) provided on March 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 
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 the provider did not submit legible progress notes that are needed in order to determine the 
clinical utility of the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the progress notes do not legibly support the need for testing. There is no documentation provided 
indicating that the test was intended to aid in 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on June 16, 2022.
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 
August 2, 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 August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (CPT code 99283) provided on November 16, 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 service is not covered as billed. 
 
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 services have not been met. Review of the information does not 
show that an appropriate place of service was billed on the claim. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit for the evaluation and management of a patient (CPT code 
99283) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve ultrasonic guidance for placement of radiation therapy. You say that you 
have skin cancer and have already started treatment. The Plan denied your request. The Plan says the request 
does not meet the Medicare or health plan coverage criteria. Your doctor requested coverage for a special type 
of radiation treatment to treat your skin cancer. There is not enough evidence that this type of radiation therapy 
guidance is needed or effective for your skin cancer. Therefore, it not considered standard of care. 
 
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 ultrasonic guidance for placement of 
radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT 
uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, 
IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be 
reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used 
when critical structures are abutting or in close proximity to the target that is being treated to high doses. This 
situation does not apply to you for which the target lesion can be seen on the skin to assist in daily set up. 
When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for 
IGRT for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general- citations below) is not 
necessary.  The decision is unfavorable as billing for daily IGRT or daily simulations (also requested in this 
case) which would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for placement of radiation therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ultrasonic guidance for placement of 
radiation therapy fields (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Upwalker. 
 
You asked the Plan to pre-approve the walker. You say that your breathing is better and easier when you move 
around. The Plan denied your request. The Plan says this is not medically necessary and excluded from 
coverage. 
 
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 walker. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
this was requested to provide postural support to reduce flexed posture during gait and to reduce pain plan 
through hands/wrists. The requested Upright walker is not indicated by Medicare as covered durable medical 
equipment.  
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Upwalker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (G0283) provided on May 10, 2022. 
 
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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT G2083 has an MUE value of 
1, and the provider billed 84 units. Therefore, we decided that the Plan does not have to pay for electrical 
stimulation (G0283) provided on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37228 billed for date of service February 2, 
2022. 
 
You asked the Plan to pay for procedure code 37228. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the available records do not support the services 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 37228 is: Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37228. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found that the operative report includes insufficient 
documentation to confirm tibial peroneal artery revascularization with transluminal angioplasty.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37228 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 37228 billed for date of service February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 16, 
2022, through August 19, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that it is felt that this inpatient admission 
was necessary. The Plan denied your request. The Plan says this stay should have been billed as outpatient 
observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is a male who presented with dizziness/syncope. A right atrial lead 
dislodgement of the dual chamber pacemaker was noted.  Vitals were stable. He was diagnosed with 
symptomatic sick sinus syndrome and was admitted to observation. He underwent lead revision which was 
uncomplicated. He remained stable hemodynamically. The enrollee was then admitted to inpatient for 
continued monitoring. However, at the time of admission, there was no expectation that he would require 
hospitalization that would likely cross 2 midnights as he was stable and tolerated the procedure without 
complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 16, 2022, through August 
19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized knee and advanced foot (K3). 
 
You asked the Plan to pre-approve a computerized knee and advanced foot (K3). You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded protheses are only covered for certain 
indications. 
 
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 computerized knee and advanced foot 
(K3). Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found the enrollee has right-sided above the knee amputation. 
A level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the community 
ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic or 
exercise activity that demands prosthetic utilization beyond simple locomotion.  In this case, the documentation 
does not indicate the enrollee is a K3 level functional level. The requested upgraded prosthesis components are 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computerized knee and advanced foot (K3) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computerized knee and advanced foot (K3).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy will be an invaluable 
adjunct to your current efforts to reduce pain and maintain functionality. The Plan denied your request. The 
Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 14, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transport provided on June 29, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say to please review the supported documents that 
detail the patients medical necessity and warrant the need for ambulance transport on the date of service. The 
Plan denied your request. The Plan says that this was a non-emergency transfer. 
 
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 the ambulance transport. Our reviewer says 
that the interfacility transfer, via ambulance, for psychiatric evaluation that was not available at the sending 
hospital was medically necessary. Our physician reviewer found the enrollee did require the expertise of 
trained personnel or the 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. 
 
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 transport have been met. Therefore, we decided that the Plan has 
to pay for ambulance transport provided on June 29, 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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injection, denosumab, 1 mg (code J0897) and injection of 
drug/substance under skin or into muscle (code 96372) provided on October 19, 2021. 
 
You asked the Plan to pay for injection, denosumab, 1 mg and injection of drug/substance under skin or into 
muscle. You say that the services were medically necessary. The Plan denied your request. The Plan says that 
the member's Plan excludes coverage for charges for or in connection with services or supplies that we 
determine to be experimental, investigational, cosmetic or not generally recognized according to professional 
standards of safety and effectiveness in the United States for diagnosis care or treatment. 
 
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 us with the rule to support their denial. Therefore, we 
decided that the Plan has to pay for injection, denosumab, 1 mg (code J0897) and injection of drug/substance 
under skin or into muscle (code 96372) provided on October 19, 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.