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

 
We decided that the Plan has to pre-approve a lower extremity angiogram/percutaneous revascularization 
(procedures code 36200, 36245, 37186, 37220, 37221, 37222, 37223, 37225, 37227, 37229, 37231, 37233, 
37235, 37252, 37253, 37197, 75625, 75710, 76937, 99152, 99153). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the guidelines have not been met. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation supports the medical necessity of the treatments in question. The patient is 
scheduled for bunion surgery but is not cleared from a vascular standpoint. The vascular provider has 
documented absent pedal pulses and evidence of severe vascular occlusive disease on duplex ultrasound. In this 
setting, diagnostic angiography and possible intervention is both reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve a lower extremity angiogram/percutaneous revascularization (procedures code 36200, 36245, 37186, 
37220, 37221, 37222, 37223, 37225, 37227, 37229, 37231, 37233, 37235, 37252, 37253, 37197, 75625, 75710, 
76937, 99152, 99153).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee had a recent lymph 
node transfer surgery and continues to have swelling of the right upper extremity. The Plan denied your 
request. The Plan says the services denied correctly as the enrollee does not meet the clinical requirements to 
be approved. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the surgical services provided on February 3, 
2022, out-of-area. 
 
You asked the Plan to reimburse you for the surgical services. You say that you should be reimbursed. The 
Plan denied your request. The Plan says that additional information is needed. 
 
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 reimburse you for the surgical services. Our 
reviewer says that is not medically necessary. Our physician reviewer found the provided documentation is not 
adequate to determine if the enrollee could have foreseen requiring the services prior to leaving their service 
area. The reviewer found that the provided documentation is inadequate to fully clarify the medical condition 
and whether the care provided was an emergency and medically necessary as required by Medicare rules. 
Therefore, the reviewer found that the services received outside of the plan's service area were 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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to reimburse you for the surgical services provided on February 3, 2022, out-of-area.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you need this machine to 
pump your legs and you have been nervous not having this machine. The Plan denied your request. The Plan 
says the requested device is not covered for the treatment of lymphedema of the extremities alone. The treating 
practitioner must provide a medical necessity determination for the PCD including symptoms, objective 
findings, and measurements to establish the conditions severity. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand controls to assist with driving a car (E1399). 
 
You asked the Plan to pre-approve the hand controls. The Plan denied your request. The Plan says this is not 
considered covered Durable Medical Equipment (DME). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve hand controls to assist with driving a car (E1399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 15, 2022, 
to March 16, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA was sent for the first 2022 
period. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
was not billed with the first period of care date in 2022 as required. Based on this information, we find that the 
Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from February 15, 2022, to March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is denied as not reasonable or 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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode which could be provided by a bilateral positive airway pressure (BiPAP) 
device with AVAPS and a back-up rate. 
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral evaluation to be provided by an Endodontist. 
 
You asked the Plan to pre-approve the oral evaluation to be provided by an Endodontist. You say that you were 
referred by an oral surgeon to an endodontist to have a procedure. The Plan denied your request. The Plan says 
the service is not a covered 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 oral evaluation to be provided by 
an Endodontist is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve the oral evaluation to be provided by an Endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says 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 at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee was seen for a wound check 8 
days after initial evaluation. It was foreseeable that a follow up after original injury would be 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 office visit have not been met.  
 
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 pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metformin tablet 1000 ER. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Metformin tablet 1000 ER.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a convergent hybrid ablation procedure (33265) with associated 
inpatient admission for the procedure. 
 
You asked the Plan to pre-approve a convergent hybrid ablation with inpatient admission. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the 
request is not medically necessary. 
 
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. The rules also say that 
inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least 
two midnights. 
 
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 convergent hybrid ablation with 
inpatient admission. Our reviewer says that the requested service is considered medically reasonable and 
necessary in this case. Our physician reviewer found that while the simpler endocardial catheter ablation 
procedure would be more appropriate for paroxysmal atrial fibrillation, proceeding directly to a convergent 
hybrid procedure would be acceptable because of the poor results of endocardial catheter ablation alone, with 
the frequent need to later carry out a convergent hybrid procedure. As a result, authorization for the 
performance of a convergent hybrid ablation procedure would be considered appropriate and reasonable in the 
enrollee's clinical management. A hospitalization spanning at least 2 midnights would be anticipated. 
 
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 convergent hybrid ablation with inpatient admission have been met. 
Therefore, we decided that the Plan has to pre-approve a convergent hybrid ablation procedure (33265) with 
associated inpatient admission for the procedure.  
 
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 limited oral evaluation (D0140) provided on October 10, 
2022 
 
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 your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 10, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Nail qPCR (polymerase chain reaction) panel (87481, 
87500, 87640, 87651, 87653, 87798, 87798) provided on August 4, 2022. 
 
You asked the Plan to pay for a Nail qPCR panel. You say that the results of this testing was medically 
necessary to establish the appropriate individualized treatment plan for this enrollee. The Plan denied your 
request. The Plan says a review of the medical literature and clinical practice guidelines do not support PCR 
testing as a first line approach for evaluation of onychomycosis and it is not widely accepted as standard of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a Nail qPCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a review of the medical literature and clinical practice guidelines do not support PCR 
testing as a first line approach for evaluation of onychomycosis and it is not widely accepted as standard of 
care. Also, outpatient point-of-care antibiotic resistance testing by PCR is particularly limited by: the diversity 
of antibiotic resistance mechanisms present in general practice; a lack of epidemiological information on the 
origin and spread of antibiotic resistance mechanisms within particular geographical locations and within 
particular communities; and limitations on currently available point of care (POC) diagnostic technologies to 
rapidly detect the many different types of antibiotic resistance mechanisms known. Further, there is a lack of 
data to suggest these panels alter medical decision making. 
 
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 Nail qPCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for a Nail qPCR (polymerase chain reaction) panel (87481, 87500, 87640, 87651, 87653, 
87798, 87798) provided on August 4, 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 the enrollee has recently decreased in overall 
functional mobilities, cognition, and medical stability therefore meeting criteria for admission to an IRF. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF. 
 
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 enrollees nursing medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has had a functional decline from their baseline level of function and would likely benefit from therapy, but 
they do not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you have a past medical history of diabetes, neuropathy, COPD, hypertension, and 
lumbar radiculopathy and are living at home with weakness and functional decline. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeve (E0673), provided on June 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says these items are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease or in a surgical center.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and suspension sleeve (E0673), provided on June 30, 2022.