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

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies billed 
for date of service October 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The durable medical equipment at issue was provided in an ambulatory 
surgical center. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies billed for 
date of service October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have 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 the home ventilator. Our physician 
reviewer found the Life2000 device is not medically necessary. The Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory support. Its primary intended use is during activity, and 
not to treat chronic carbon dioxide (CO2) retention during sleep. There is inadequate evidence of the safety and 
effectiveness of this device in the treatment of COPD. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the right ankle orthotic (L1971) provided on November 2, 2022. 
 
You asked the Plan to pay for the orthotic. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says that the provided documentation does not support the billed supply code. 
 
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 contains a valid proof of delivery for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the right ankle orthotic (L1971) provided on November 2, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 72 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 89 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on September 6, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
September 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that you need 
transportation to dialysis appointments. The Plan denied your request. The Plan says the requested 52 trips will 
exceed your trip limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will exhaust the Plan maximum benefit for coverage of routine transportation with the requested 
number of trips. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine 
transportation beyond the Plan's 24-trip limit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE testing. You say that this is needed to assess cardiac structure and 
function. The Plan denied your request. The Plan says this 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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation does not point to a change in status that would support the necessity of a TTE 
test to assess cardiac structure and function. Clinical guidelines do not support performing TTE with no 
intervening change in clinical status or new signs, symptoms, or physical findings. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 64447. The Plan denied your request. The Plan says payment for 
code 64447 is bundled into payment for code 01402. 
 
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 64447 
is a column II code to column I code 01402. 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 64447 billed for date of 
service October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic product (0627T). 
 
You asked the Plan to pre-approve a percutaneous injection of allogeneic product. You say that the requested 
services are a medical necessity for you. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 percutaneous injection of allogeneic 
product. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the request is for an experimental/investigational procedure. 
 
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 percutaneous injection of allogeneic product have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic product (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device billed for date of service October 15, 2022. 
 You asked the Plan to pay for the billed services. You say that the code is an accepted procedure code. The 
Plan denied your request. The Plan says the device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the enrollee was being treated for low back 
pain of more than a year. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous 
electrical nerve stimulation (TENS) device billed for date of service October 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on October 13, 2021, to 
October 14, 2021. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay 
provided on October 13, 2021, to October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on September 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was for use during surgery. The 
Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. The claim shows that the services at issue were provided in an ambulatory 
surgical center. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device and related supplies provided 
on September 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-area referral for physical therapy. 
 
You asked the Plan to pre-approve the referral. You say that you are out of the area until mid-May, and the 
services are needed for restoration of shoulder function. The Plan denied your request. The Plan says physical 
therapy is available in the network. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
chronic shoulder pain, with no urgent or emergent issues identified. This is available in the service area. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-area referral for physical therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service May 28, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that these services were necessary and are 
supported in the records provided. 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 claim lines submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1. If a code has an MAI of 1, appropriate use of 
a modifier may be used to report the same code on separate lines of the claim, and each line for that code will 
be separately evaluated against the MUE value for that code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 298 units of 
this code on a single line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service May 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99215) and a telephone evaluation 
(99443) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and a telephone evaluation. You say that the requested facility 
is the only medical office where complete records exist. You took the complete test at the requested clinic and 
need to read it. You could have cancer. Without the results of the test, you will not know and could miss 
needed treatment. The Plan denied your request. The Plan says your records received do not indicate that you 
have an emergent or urgent medical condition or are in need of specialized service(s) that are not available in 
the network. You have an HMO (Health Maintenance Organization) plan. There are in-network provider(s) 
within a reasonable distance from your location that can provide this service or item. 
 
 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 
an office visit (99215) and a telephone evaluation (99443) to be provided by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary because 
the enrollee has a special feeding tube, is malnourished and weak, and needs to have antibiotics administered 
intravenously. The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary. 
 
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 that the enrollee was admitted for repair of an abdominal aortic aneurysm and has 
had a complicated hospital course. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. Our reviewer found the elements of the coverage 
rules are not satisfied.   
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation that your oxygen saturation (SpO2) can be maintained greater 
than 91 percent during activity, using an oxygen conserving device, at a flow rate of 1 to 4 L/min. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).