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

 
We decided that the Plan does not have to pre-approve referral to an out-of-network (OON) academic provider 
with expertise with restless leg syndrome (RLS). 
 
You asked the Plan to pre-approve the OON RLS specialist referral. You say that your current provider has told 
you that he cannot offer you any other treatments, and the ones you have tried have had side effects that 
interfere with your quality of life. You feel that the only option for you is to be seen by a specialist with 
specific expertise in RLS. The Plan denied your request. The Plan says your needs can be met by network 
providers. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve the OON RLS specialist referral. Our 
reviewer says that the documentation does not support that referral to the OON specialist is medically 
reasonable and necessary at this time. Our physician reviewer found the records show that the enrollee has a 
history of RLS and sleep apnea. The limited records provided for review indicated that the enrollee's RLS had 
mostly been adequately managed. There was no documentation provided that the RLS was inadequately 
managed, nor was it clear that there is/was a network deficiency that would require referral/consult with an out 
of network academic provider. In as much based on the information provided, it appears that the enrollee's 
clinical needs can be met via in-network providers. 
 
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 OON RLS specialist referral have not been met. Therefore, we decided that 
the Plan does not have to pre-approve referral to an out-of-network (OON) academic provider with expertise 
with restless leg syndrome (RLS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cold or hot fluid bottle, ice cap or collar, heat and/or cold 
wrap, any type (A9273) and miscellaneous Durable medical equipment, device kit (E1399) provided May 22, 
2022, to June 22, 2022. 
 
You asked the Plan to pay for the Dignicap scalp cooling system. You say that your provider said you need 
scalp cooling during the course of chemotherapy. The Plan denied your request. The Plan says this device is 
statutorily non-covered by Medicare. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the Dignicap scalp cooling system have not been met. Therefore, we decided that the Plan does not 
have to pay for Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type (A9273) and 
miscellaneous Durable medical equipment, device kit (E1399) provided May 22, 2022, to June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable eCoin device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this eCoin service is considered 
experimental and 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is a lack of well controlled studies demonstrating long term safety and effectiveness of eCoin. 
The studies evaluating this device have had small sample sizes and lack controls and randomization of subjects. 
In addition, there have been no studies demonstrating effectiveness of eCoin in patients who have failed other 
methods of neuromodulation. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the implantable eCoin device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leads (A4595), provided on June 9, 2022. 
 
You asked the Plan to pay for the leads. You say that the item is medically necessary. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
 
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 a valid proof of delivery for the supplies provided in this case. The itemized 
delivery ticket does not include the item at issue, leads. 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 leads (A4595), provided on June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that you are tired of standing up in the shower 
and the shower chair you have is not comfortable. You also say that the regular tub was built too low for you to 
sit. The Plan denied your request. The Plan says a walk-in bathtub does not serve a medical purpose. 
 
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 a walk-in bathtub.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 26, 2022, to 
May 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the charges are allowable, and 
the claim should be reconsidered for payment. 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, an 
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 reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first 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 April 26, 2022, to May 
25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections for migraines. 
 
You asked the Plan to pre-approve the requested Botox injections. You say that it is felt that this treatment is 
medically necessary. The Plan denied your request. The Plan says neither the LCD criteria nor step therapy 
rules have been met in this case.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 requested Botox injections. Our 
reviewer says that the requested treatment is not supported by either the LCD or the Plan's step therapy rules. 
Our physician reviewer found the record indicates that the enrollee has chronic migraines without aura. The 
record provided does not indicate that the enrollee has headache occurring on 15 or more days a month for 
more than three months, which, on at least eight days/month has the features of migraine headache. As such, 
the LCD criteria are not met. 
 
In addition, prior to approval of Botox, the Plan requires a trial of two of the following (from at least two 
different drug classes): topiramate, divalproex, valproic acid; propranolol, metoprolol; amitriptyline, or 
venlafaxine. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step 
one alternative. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the plan's preferred step one alternative. 
 
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 requested Botox injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Botox injections for migraines.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee needs the ventilator to stay 
alive and to reduce readmissions. The Plan denied your request. The Plan says the Medicare rules have 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 the home ventilator. Our physician 
reviewer found there is no documentation of failure of bilevel positive airway pressure (BiPAP). The enrollee 
may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep.  But Medicare 
does not cover a home ventilator when uses as 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77001 and 99153 billed for date of service 
April 27, 2022. 
 
You asked the Plan to pay for procedure codes 77001 and 99153. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 77001 is bundled into payment for code 
49083. 
 
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 77001 
is a column II code to column I code 49083. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
Medicare rules say that providers must report services correctly. Technical components must be billed by the 
facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. The records 
indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code(s) 99153. This means there is a 
technical component only for CPT code 99153. In this case, an appropriate modifier has not been billed with 
CPT code 99153. 
 
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 codes 77001 and 99153 billed for date of service April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on August 
8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three heavy duty power wheelchair (PWC) with 
multiple power options (K0862). 
 
You asked the Plan to pre-approve a group 3 PWC with multiple power options. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group three power wheelchair to be covered the 
criteria in the Medicare Rules section must be met. 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 group 3 PWC with multiple power 
options. Our reviewer says that this item is not medically necessary. Our physician reviewer found the enrollee 
does not have conditions requiring power recline or power tilt or tilt and recline; does not have the skin or 
spasticity or ventilator requirements for power drives power drives. 
 
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 group 3 PWC with multiple power options have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group three heavy duty power wheelchair (PWC) with 
multiple power options (K0862).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (PTNS). 
 
You asked the Plan to pre-approve PTNS procedure. You say that medications have not worked for you. The 
Plan denied your request. The Plan says you do not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that PTNS may be covered for enrollees that have failed 
treatment with two anticholinergic drugs, each taken for at least 4 weeks, or have intolerance to anticholinergic 
drug therapy. 
 
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 PTNS procedure. Our reviewer says 
that you do not meet criteria for the requested PTNS procedure. Our physician reviewer found the record does 
not show that you have failed treatment with two anticholinergic drugs - each taken for at least 4 weeks - or are 
intolerant to anticholinergic drug therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTNS procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve posterior tibial nerve stimulation (PTNS).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 25, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to move to a closer facility for the family 
and that you still need rehabilitation services before returning home. The Plan denied your request. The Plan 
says your records do not show that you require skilled nursing services daily. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging. 
 
You asked the Plan to pre-approve gastrointestinal tract imaging. 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 follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when certain conditions are met. 
 
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 gastrointestinal tract imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has iron deficiency anemia. The record indicates that the enrollee has 
hemorrhoids. The record indicates that the enrollee has not had a coloscopy or esophagogastroduodenoscopy in 
over five years and does not indicate that the site of bleeding could not be previously identified by such 
standard testing. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve gastrointestinal tract imaging.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 27, 2022.