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

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies coded A4595 provided on September 2, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the supplies provided are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The information submitted by the provider does not corroborate the documentation in the enrollee's 
medical documentation to confirm that coverage criteria have been met. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies coded A4595 
provided on September 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services coded A0432 provided on 
February 17, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that specific elements are required on transportation 
claims. 
 
We looked at the file and Medicare rules. Review of the file shows that the paramedic intercept services were 
not billed with the appropriate mileage code and modifier. Without this information, the claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the paramedic intercept 
services have not been met. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services coded A0432 provided on February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery (67900, 21137, 21138, 
21139). 
 
You asked the Plan to pre-approve facial feminization surgery. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
cosmetic in nature and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 facial feminization surgery. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our reviewer 
found that the record provided does not document the need to correct deformities created by congenital defects, 
trauma, or medical conditions. The record provided does not document the presence of functional 
impairments. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules,  of the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facial feminization surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facial feminization surgery (67900, 21137, 21138, 21139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is a diagnosis of chronic obstructive pulmonary disease (COPD), but this is not documented 
with pulmonary function tests. This patient may benefit from bilevel positive airway pressure (BiPAP) with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP.  
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 ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Freestyle 2 sensor kit (K0553) provided on November 4, 2022. 
 
You asked the Plan to pay for the CGM. You say that the CGM was necessary. The Plan denied your request. 
The Plan says that the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM. Our physician reviewer found the 
enrollee using is using insulin eight times a day; while we are not shown a sliding scale, it is hard to imagine a 
regimen using insulin eight times a day that does not involve some adjustment based on blood glucose level; 
therefore, the enrollee meets criteria. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pay for the 
Freestyle 2 sensor kit (K0553) provided on November 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection (64483). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says the epidural steroid injection is considered not 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 injection. Our physician reviewer 
found the LCD require advanced imaging prior to interventions. The request is deemed not medically and 
reasonable. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural injection (64483).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA, a special kind of picture of the blood vessels in 
your stomach, without and with contrast (dye) (74175). 
 
You asked the Plan to pre-approve the CTA scan. You say that the CTA scan is medically necessary. The Plan 
denied your request. The Plan says the CTA scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CTA scan. Our physician reviewer 
found it appears the order for a CTA of the abdomen is a mistake and the intention was to order a CTA of the 
chest to check the repaired ascending thoracic aortic aneurysm. As such, the request for CTA should be for the 
chest rather than the abdomen per the physician's stated plan in the records during the encounter of February 
15, 2023. 
 
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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CTA, a special kind of picture of the blood vessels in your stomach, without and with 
contrast (dye) (74175).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve routine transportation. You say that the Plan has approved this for you 
before. The Plan denied your request. The Plan says routine transportation beyond 50 miles per one-way trip is 
not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. The requested destination is beyond 50 
miles per one-way trip. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation mileage.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 billed for May 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
Explanation of Benefits (EOB) from the primary insurer on two occasions and has not received a response.. As 
the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for procedure 
codes 99285 and 93010 billed for May 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that Actemra is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Actemra. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the provided medical records in this case do not 
document any lung imaging or pulmonary function testing to confirm the diagnosis of systemic sclerosis-
associated interstitial lung disease. The proposed dosing of Actemra at 4 mg/kg intravenously is not supported 
for systemic sclerosis-associated interstitial lung disease or for systemic scleroderma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, 99072, S1015, 
S8301, and 01941 billed for date of service September 15, 2022. 
 
You asked the Plan to pay for procedure cods A4556, A4557, A4649, 99072, S1015, S8301, and 01941. You 
say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure 99072 is not separately payable. Codes A4556, A4557, and A4649 have a status indicator of P on the 
Physician Fee Schedule. This means that procedures A4556, A4557, and A4649 are bundled/excluded from 
payment. Procedure codes S1015 and S8301 have a status indicator of I on the Physician Fee Schedule. This 
means that procedure codes S1015 and S8301 are invalid for Medicare purposes. 
 
The rules say that f or the single medically directed service, the physician will use the QY modifier and the 
qualified nonphysician anesthetist will use the QX modifier. 
 
The file shows that procedure code 01941 was not billed with a required anesthesia modifier. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes A4556, A4557, A4649, 99072, 
S1015, S8301, and 01941 billed for date of service September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent Inj 75mg/ml. 
 
You asked the Plan to pre-approve a prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested medication is on the self-administered drug list and is 
excluded from coverage under Part B. 
 
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 Praluent Inj 75mg/ml.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99053 and 99284 billed for date of service 
October 2, 2022. 
 
You asked the Plan to pay for procedure codes 99053 and 99284. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the services are not covered. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met.  
 
Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2.  
 
In this case, the MUE for CPT code 99284 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
99284 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99053 and 99284 billed for date 
of service October 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 8, 
2022. 
 
You asked the Plan to pay for procedure code 70544. The Plan denied your request. The Plan says payment for 
code 70544 is bundled into payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service October 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer. The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion interspinous 
spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that FDA contraindications include spinal instability, scoliosis, obesity, 
and osteoporosis, and have not been adequately addressed in the medical records. There is with no discussion 
of spinal instability on flexion/extension films. Height is 167.64cm, weight is 97.6 kg, and body mass index is 
34.73 kg/m2. There is no discussion of scoliosis of the lumbar spine, with no documentation of the Cobb angle. 
There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in 
this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
spacer at L2-3 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 Vertiflex Superion interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says there is not enough evidence that this 
device would improve the enrollee's outcome. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 20, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 20, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 
81272.