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

 
We decided that the Plan does not have to pay for procedure code 99337 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 99337. You say that you billed this service properly. The Plan 
denied your request. The Plan says you billed this service with an incorrect Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 99337 is a code used for 
domiciliary, rest home, or custodial care evaluation and management services provided to residents residing in a facility which provides room, board, and other personal assistance services. This code is assigned to POS 
codes of 13 (Assisted Living Facility), 14 (Group Home), 33 (Custodial Care Facility), and 55 (Residential 
Substance Abuse Facility). In this case, you did not bill with one of these POS codes.  Instead, you billed with 
POS code 12, which indicates the service was performed in the patient's home.  That is not the correct POS for 
use with this procedure code. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99337 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99337 billed for date of service March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis provided to the enrollee on August 16, 2021. 
 
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 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 20610 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 20610- aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); 
without ultrasound guidance- was rendered in this case. Detailed documentation is not evident regarding any 
injections having been provided on 8/16/21 supporting the CPT code 20610. There is no compelling rationale 
presented or extenuating circumstances noted to support the appropriateness of this request as an exception.  
 
We looked at this coder'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 arthrocentesis provided to the enrollee on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the requested MRI is medically 
necessary. The Plan denied your request. The Plan says the request for an MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the cervical spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee had no 
findings on neurological exam that localize to the cervical spine. She is noted to have had similar imaging 
completed last year and there was no mention of a significant interval change from the time of prior imaging. 
In as much it cannot be determined that a new study would otherwise be reasonable and necessary at this time. 
 
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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you feel that this device is medically necessary for 
the enrollee and ask for authorization of a continuous rental as long as he needs it. The Plan denied your 
request. The Plan says the criteria has not been met for the requested device but the enrollee meets the criteria 
for 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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The Life2000 system is not medically necessary. This system is not a true ventilator, because it is not capable of providing full ventilatory support. It is designed to be used with activity. There is inadequate 
evidence that it is effective in the treatment of chronic lung disease. The enrollee does not qualify for a home 
ventilator or nocturnal ventilatory assistance because there is no ABG, done while stable, showing chronic CO2 
retention. 
 
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 home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is 
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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess 
safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for 
upper extremity paralysis/paresis from conditions such as stroke, brain injury, or other 
neuromuscular/neurological disease or injury. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee is in a severe depressive 
state and needs inpatient care. You say that the enrollee continues to have hallucinations and is paranoid. The 
Plan denied your request. The Plan says the enrollee does not have medical issues that require treatment at the 
inpatient level of car. The Plan says that the enrollee could be treated safely and effectively at a lower level of 
care. 
 
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 criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric hospitalization on July 1, 2022, with Major Depressive Disorder, Recurrent, 
Severe with Psychotic Features and Generalized Anxiety Disorder. Based upon review the records provided it 
was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he 
was not showing any dangerousness to others but did have passive suicidal ideation without a plan, auditory or 
visual hallucinations he was without aggressive behaviors and not showing any acute threats of safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question. This patient did show some paranoia. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the patients condition or 
for the purpose of diagnosis. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (CPT 91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that a wireless capsule endoscopy is 
medically necessary. The Plan denied your request. The Plan says a wireless capsule endoscopy does not meet 
the Medicare LCD coverage criteria 
 
The Plan follows Medicare 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 pre-approve a wireless capsule endoscopy. Our 
reviewer says that a wireless capsule endoscopy is not medically necessary. Our physician reviewer found that 
the enrollee has iron deficiency, but the enrollees available records do not support that the enrollee is anemic, 
is exhibiting signs of GI bleeding, nor that the enrollee meets the Medicare LCD indications for wireless 
capsule endoscopy. Specifically, the enrollee has not undergone colonoscopy within the past 12 months. 
Further, the provider opined that nodular gastritis might contribute to the enrollees iron deficiency state. 
The available records further do not support suspicion of carcinoid tumors of the small bowel, of celiac disease, 
IBD, small bowel tumors associated with familial cancer syndromes, nor of esophageal varices. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (CPT 91110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for registered nurse first assistant (RNFA) services provided on 
February 2, 2022. 
 
You asked the Plan to pay for the RNFA services. You say that the RNFA services were the only surgical 
assistant services available, so this should be covered. The Plan denied your request. The Plan says services by 
an RNFA are not payable by Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for registered nurse first assistant 
(RNFA) services provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 27, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on 
December 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim 
reprocessed as you were not aware of a prior authorization requirement. The Plan denied your request. The 
Plan says prior authorization was not obtained for this equipment provided 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. 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 (K0606) 
provided on December 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the registered nurse first assistant (RNFA) services provided 
on January 13, 2022. 
 
You asked the Plan to pay for the RNFA services. You say that RNFA services were the only assistant services 
available at the time, so this should be covered. The Plan denied your request. The Plan says an RNFA is not a 
recognized provider type eligible for Medicare payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the registered nurse first assistant 
(RNFA) services provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prolotherapy of the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says currently, the requested service is not a covered service by Medicare guidelines. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Additionally, the documentation 
provided did not include any updated exams that documented any sustained functional benefit or a decrease in 
pain levels from the previous treatments/prolotherapy of the bilateral SI joints on 1/12/22 and 4/13/22. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested prolotherapy of the sacroiliac joint, in this case, is not 
medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prolotherapy of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services you received on February 23, 2022. 
 
You asked the Plan to pay for the dermatology services. You say that you always use this provider and 
previous claims were paid. The Plan denied your request. The Plan says this provider as opted-out of Medicare, 
so no payment can be made. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dermatology services you received on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 24, 
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 laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services 
and is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this equipment is necessary for the difference in 
length of your left leg. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary for treatment of your chronic blood clots. The Plan denied your request. The Plan says the 
item being requested is not covered item for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage for this device have not been 
satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).