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 ventilator. You say that the requested ventilator is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the records do not show failure of treatment with 
bi-level positive airway pressure (BiPAP). The Plan says that the records also do not show that the requested 
device will not be used exclusively in bi-level PAP mode. The Plan also says that the requested ventilator is 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 a ventilator. Our reviewer says that the 
requested home ventilator is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD). The 
reviewer found that the provided records do not document trial and failure of a bi-level positive airway pressure 
(BiPAP) device with average volume-assured pressure support (AVAPS) and a back-up rate. The reviewer 
found that ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy 
for the enrollee's diagnosis are not medically reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 96360 rendered on September 
26, 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 claim not payable as submitted.  
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 terms of CPT 930005, it cannot be paid separately if it's billed on the same claim as a code that has a status 
indicator of V. CPT 99285, which was billed on the same claim, has a status indicator of V. 
 
In terms of CPT 96360, the local coverage article guidelines for appropriate diagnoses specify certain 
diagnoses as coverable for this code. None of the covered diagnoses for CPT 96360 were used in this case. 
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 procedure codes 93005 and 96360 rendered on 
September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you are requesting reconsideration stating the 
enrollee has severe COPD. She can benefit greatly from HFCWO, and this pulmonary therapy is essential to 
her health. The Plan denied your request. The Plan says the requested HFCWO does not meet the requirements 
for approval. The records do not show that the enrollee has a diagnosis of a cystic fibrosis, neuromuscular 
disorder, or bronchiectasis and well documented failure of standard treatments. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD. There is no diagnosis 
of cystic fibrosis, bronchiectasis, or neuromuscular disease. Medicare does not cover this device for COPD or 
chronic bronchitis because there is inadequate evidence of safety and effectiveness for these diagnoses. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
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 you are requesting reconsideration 
for the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee's medical 
conditions are not sufficiently complex or severe enough to require an LTACH level of care. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT) (77373x5, 
77470x5). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found delivering high fractional doses in 2-5 fractions is an established approach for the treatment of 
discrete lesions from cancer. There is abundant data on the use of SBRT for discrete lesions from presumed 
(i.e., clinically diagnosed) Stage I non-small cell lung cancers in the absence of pathology (references linked 
below). It is acceptable to make a diagnosis of clinical Stage I NSCLC when an enrollee declines a biopsy, or 
the biopsy is not feasible. This enrollee developed a pneumothorax after a biopsy attempt. A PET/CT would be 
ideal and should be attempted with anxiolytics and perhaps this could be required prior to approval. The 
ASTRO model coverage policy states that SBRT for primary lung cancer is considered medically necessary. 
This model policy reflects not only expert opinion, but is also evidence-based, based upon published literature. 
SBRT is only considered medically necessary for enrollees with good medical condition/performance status 
and for those whose tumor burden can be targeted, which appears to apply for this case. The decision is that the 
SBRT was medically necessary- as our reviewer believes it would be furnished in accordance with accepted 
standards of care. A PET/CT would be ideal and should be attempted with anxiolytics and perhaps this could 
be required prior to approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Body Radiation Therapy (SBRT) (77373x5, 77470x5).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-ray, panoramic x-ray, 
cleanings, a limited oral evaluation, cone beam computed tomography (CT) scan, and unspecified preventive 
procedure (D0120, D0272, D0330, D1110, D0140, D0380, D1999, D0272). 
 
  You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the claim for 
services received on October 7, 2021, was received untimely. The services provided from May 3, 2022, to 
November 8, 2022, denied correctly as they were provided by an out-of-network provider. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services provided in 2021 was not filed until November 2, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
 
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. 
 
The record shows you received the requested dental services in 2022 from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for a periodic oral evaluation, bitewing x-ray, panoramic x-ray, cleanings, a limited oral evaluation, 
cone beam computed tomography (CT) scan, and unspecified preventive procedure (D0120, D0272, D0330, 
D1110, D0140, D0380, D1999, D0272).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dermatology visit. You say that this service is medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
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 
a dermatology visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and Thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure improves the quality of 
life of enrollees suffering from vertebrogenic low back pain. The Intracept procedure, not just the device 
received initial FDA clearance the summer of 2016. That clearance means the procedure is safe and effective. 
The Plan denied your request. The Plan says there is insufficient evidence to determine that radiofrequency 
ablation of the basivertebral nerve improves health outcomes. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. More research is needed 
to show efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and Thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provide on 
December 9, 2021, to November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provide on December 9, 2021, to November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical boot (L3260-RT) provided on August 30, 2022. 
 
You asked the Plan to pay for the surgical boot. The Plan denied your request. The Plan says the claim was 
coded incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code L3260-RT is not supported in the medical record. Specifically, the claim 
was billed with an unspecified diagnosis code. It is inappropriate to bill modifier -RT with an unspecified 
diagnosis code. When modifier -RT is appended, a right-sided diagnosis code should be billed. Based on this 
information, we decided that Medicare rules for coverage of the surgical boot have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical boot (L3260-RT) provided on August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says based on the clinical information received, the 
enrollee does not meet the guidelines for IRF services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ViviGen allograft. 
 
You asked the Plan to pre-approve ViviGen allograft. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Vivigen allograft is experimental when used as bone graft in spinal surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
February 25, 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 services are not supported without the required documentation. 
 
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 99223 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 enrollee was admitted and 
was treated surgically and improved. The documentation doesn't support that the enrollee had a comprehensive 
history or any issues that required a high complexity of medical decision making on the date of service in 
question. 
 
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 subsequent hospital care (procedure code 99233) rendered on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702) with an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that you disagree with the denial The 
Plan denied your request. The Plan says neither Medicare nor the Plan cover this request. Medical studies have 
not proven this service is helpful for the treatment of the enrollee's health problems. 
 
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 requested device is experimental and 
investigational. More research is needed to show efficacy. Based on this information, we decided that Medicare 
rules for coverage of a MyoPro orthotic device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro orthotic device (L8702) with an out of network (OON) provider.