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

 
We decided that the Plan does not have to pre-approve knee orthosis (L1843). 
 
You asked the Plan to pre-approve the orthosis. You say that the enrollee has pain in left knee with primarily 
medial compartment degenerative changes. The Plan denied your request. The Plan says the records do not 
support that the enrollee meets the requirements for approval. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not contain documentation of a recent injury to or a surgical procedure on the 
knee, or objective description of joint laxity. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthosis (L1843).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for seven years and has failed more than 6 months of conservative approaches to 
treatment. You say that you highly recommend this minimally invasive procedure when conservative treatment 
has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. 
The Plan says the documentation does not support the FDA indication for the device. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found an interspinous stabilization device is experimental and 
more research is needed. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies, 
provided on November 25, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the items were obtained through a unsolicited phone call. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) and supplies, provided on November 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural injection while you are asleep/under moderate 
sedation. 
 
You asked the Plan to pre-approve an epidural injection while you are asleep/under moderate sedation. You say 
that you need this type of anesthesia as the local anesthesia that you have tried does not block out the pain and 
you feel "everything going in" during the injection procedure. You say that you have a heart condition of 
irregular heartbeat, which is affected greatly during procedures due to anxiety and when you are given the 
anesthesia via intravenous verses local it also helps you to stay calm and keeps from further aggravating your 
heart condition and helps control your breathing, which is important because you have asthma. The Plan denied 
your request. The Plan says that epidural injection while you are asleep/under moderate sedation does not meet 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that occasional minimally to moderate conscious sedation 
is appropriate and if monitored anesthesia care is utilized the need for such stations should be clearly 
documented in the medical record. 
 
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 epidural injection while you are 
asleep/under moderate sedation. Our reviewer says that an epidural injection while you are asleep/under 
moderate sedation is medically necessary. Our physician reviewer found that you are an American Society of 
Anesthesiology (ASA) 3 risk assessment due to his obesity, obstructive sleep apnea and Chronic obstructive 
pulmonary disease (COPD). It is medically reasonable and necessary to have an Anesthesia provider administer 
sedation while you are in the prone position. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injection while you are asleep/under moderate sedation have been met. 
Therefore, we decided that the Plan has to pre-approve epidural injection while you are asleep/under moderate 
sedation.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from November 27, 2020, 
through December 8, 2020, at DRG 535. 
 
You asked the Plan to pay for the inpatient services. You say that the documentation supports the secondary 
diagnosis of E43, and the hospital should be reimbursed at DRG 535. The Plan denied your request. The Plan 
says the record does not support diagnosis code E43 which results in a change from DRG 535 to DRG 536. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code, E43, defined as unspecified severe 
protein-calorie malnutrition. 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 inpatient 
services. Our reviewer says that the documentation does not support the diagnosis code of E43. Our physician 
reviewer found that while the enrollee's underlying medical condition placed them at risk for malnutrition, and 
some degree of malnourishment was evident, the diagnosis of severe malnutrition was not supported by the 
clinical information in the medical record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from November 27, 2020, through December 8, 2020, at DRG 535.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 26, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 26, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on August 26, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you felt like you could be having a heart 
attack. You say that you felt you were not able to drive yourself to the hospital. You also say that your 
symptoms improved in the ambulance. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on August 26, 2021.
Appeal type: Hospice
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 November 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you were not able to sit upright on your 
own. You say that the ambulance was ordered by the facility upon discharge from the hospital. You also say 
that you should not be responsible. The Plan denied your request. The Plan says your claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify your coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. 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 November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and 
wheelchair van mileage (S0209) provided on October 22, 2021. 
 
You asked the Plan to pay for the transportation services. You say that you were advised the enrollee would 
receive better treatment at a different facility. You also say that you were never told that the Plan would not 
cover the transportation charge. The Plan denied your request. The Plan says the non-emergency transportation 
services were rendered without prior authorization. The Plan also says there are multiple skilled nursing 
facilities in a closer proximity to the hospital. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and wheelchair 
van mileage (S0209) provided on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Life2000 system is not a 
true ventilator because it does not have the capability of full ventilatory support. There is insufficient evidence 
of safety and efficacy in the treatment of any lung disease. The enrollee also does not meet criteria for a 
respiratory assist device during sleep.  Pulmonary function testing shows evidence of airways obstruction, and a venous blood gas suggests carbon 
dioxide retention during acute illness. But there is no arterial blood gas (ABG) study confirming hypercarbia 
when the enrollee is not acutely ill. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Life2000 system.
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 that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says LTACH care 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 the enrollee was admitted with altered mental status and subdural hematoma. The 
record indicates that the enrollee is improving but requires acute care services to be able to go to a lower level 
of care. 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 he is not currently receiving but that would be 
available at the LTACH facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belbuca. 
 
You asked the Plan to pre-approve Belbuca. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
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 Belbuca.  
 Benefits for Belbuca 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 pre-approve the Optimizer Smart permanent cardiac contractility 
modulation (CCM) system (0408T) for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational because it is not identified as widely used and generally accepted as reported 
in nationally recognized peer-reviewed medical literature. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM 
system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized 
clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from 
multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective 
functional capacity. While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, 
CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart permanent cardiac contractility modulation (CCM) system (0408T) 
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 5, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric 
care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
coverage for inpatient psychiatric care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically reasonable and necessary in this case. Our 
physician reviewer found that based upon review of the available records, it was not expected that you would 
improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal 
ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any 
symptoms which would require acute treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care from May 5, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that your previous dentures were 
ill fitting, painful, and protruding out of your mouth. You also say that you only need the top denture redone. 
The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is 
limited to one procedure every five plan years. The record shows that you received a complete maxillary 
denture (D5110) on January 24, 2020 and your complete maxillary denture (D5110) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture 
(D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6065) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says dental implants are not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants (D6065) to be provided by a participating provider.