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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and an appliance for 
use with a pneumatic compressor, full leg (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and an appliance. You say that there is not an in-
network provider for the enrollee who can provide this medically necessary treatment for her lymphedema 
condition. You also say you are requesting a network gap exception authorization for treatment. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. The 
requested items are available with an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 pneumatic compressor (E0651) and an appliance for use with a pneumatic compressor, full leg (E0667) to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endovascular revascularization services provided to the 
enrollee on May 6, 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 denied code is not supported by the records 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 this case, the CPT Code Manual definition of code 37229 is "Revascularization, endovascular, open or 
percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the 
same vessel, when performed." 
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 documentation does not 
support the use of code 37229. This codes for atherectomy with or without balloon angioplasty of a 
tibioperoneal artery. The operative report documents atherectomy and angioplasty of the superficial femoral 
artery and this appears to have been coded and covered. However, there is no documentation that any tibial artery treatment was performed. CPT 37229 would not apply here. 
 
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 endovascular revascularization services provided to the enrollee on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you use a walking stick, but your condition 
has worsened, and you are hardly able to get around. The Plan denied your request. The Plan says there is no 
signed physician order or supporting clinical documentation provided for the requested scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the power scooter have been met. 
There is no signed physician order and clinical records to support the requested scooter was not provided. The 
Plan also verified with the provider's office that an order was not provided because the doctor does not feel that 
the requested scooter is appropriate. The Plan made multiple attempts to obtain this information from the 
provider without success. Therefore, we decided that the Plan does not have to pre-approve the power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliance. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says pneumatic compression devices are not 
covered by Medicare without required documentation. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The documentation to include measurements establishing severity of the condition and clinical response to an 
initial trial treatment with the device have not been submitted for review. This means that the file does not 
show that you have lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device and appliance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a handheld low-vision aid (V2600). 
 
You asked the Plan to pre-approve a handheld low-vision aid. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that low-vision aids will be denied as noncovered. 
Based on this information, we decided that Medicare rules for coverage of a handheld low-vision aid have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a handheld low-vision aid (V2600).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0483) provided on December 23, 2021.
You asked the Plan to pay for the drug testing. You say that this was billed correctly. The Plan denied your
request. The Plan says that the records show that only 18 drug classes were tested.
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 find that code G0483 is not supported in the medical record. Specifically, the lab result report
does not show that 22 or more drug classes were tested for. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing (G0483) provided on December 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantable loop recorders are coverable when 
medically necessary and when the patient meets certain criteria. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pre-approve an implantable loop recorder. Our reviewer says that the requested implantable loop 
recorder is not medically necessary. Our physician reviewer found the patient has no history of atrial 
fibrillation, nor are there any significant cardiac arrhythmias noted on EKG monitoring. A recent randomized 
clinical trial found that continuous monitoring for atrial fibrillation with an implantable loop recorder (followed 
by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history 
of atrial fibrillation (1). At this time, insertion of an implantable loop recorder would not be considered 
medically appropriate and necessary in this patients clinical 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism purchased on November 16, 2021. 
 
You asked the Plan to pay for these services. You say that the provider had the best price with a veteran 
discount. The Plan denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism 
purchased on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a naturopathic physician. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says naturopathy physicians are not paid by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pre-approve a referral to a naturopathic physician.
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 9, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. 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 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553) 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you are requesting the denial for the 
Freestyle Libre be re-evaluated in order for the enrollee to check their blood glucose more routinely and with 
less burden. The Plan denied your request. The Plan says the records do not support that this request is 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biopsy of thyroid (60100) with ultrasonic guidance 
(76942) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a thyroid biopsy with ultrasonic guidance. You say that the services at issue 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
OON care have not been met. 
 
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 biopsy of thyroid (60100) with ultrasonic guidance (76942) to be provided by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing received on March 16, 2022 minus any cost share 
requirement. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was to determine the level of 
donor DNA that is present in your system to make sure the new lungs your received are not being rejected. The 
Plan denied your request. The Plan says that the services received are not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred and received the genetic testing by a contract provider. The file does not show that the Plan 
provided notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic 
testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the genetic 
testing received on March 16, 2022, minus any cost share requirement.  
 
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 pre-approve therapeutic parenteral drug-single administration 
(D9610) and alveoloplasty not in conjunction with extractions  four or more teeth or tooth spaces, per 
quadrant x2 (D7320). 
 
You asked the Plan to pre-approve dental services. You say that you are unable to chew and eat properly, so 
you really need this procedure. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
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. Therapeutic parenteral drug-
single administration (D9610) and alveoloplasty not in conjunction with extractions  four or more teeth or 
tooth spaces, per quadrant x2 (D7320) are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested therapeutic parenteral 
drug-single administration (D9610) and alveoloplasty not in conjunction with extractions  four or more teeth 
or tooth spaces, per quadrant x2 (D7320) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve therapeutic parenteral drug-single administration (D9610) 
and alveoloplasty not in conjunction with extractions  four or more teeth or tooth spaces, per quadrant x2 
(D7320).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you feel the enrollee's services ended too soon and 
feels that additional care is necessary. The Plan denied your request. The Plan says the enrollee's needs can be 
served through home or assisted living facility discharge plan with appropriate supervision. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) provided on June 13, 
2022. 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that you disagree with the denial and 
are requesting reimbursement for the device. The Plan denied your request. The Plan says the requested device 
is listed as not covered when purchased. Per Medicare guidance, oxygen equipment is only covered when 
rented. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. The records show that you purchased the oxygen concentrator. 
Medicare confirms oxygen equipment is eligible for coverage when rented. Based on this information, we 
decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we 
decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) provided on June 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device.  
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is not able to operate a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is only covered under certain 
medical indications.  
 
The file shows that the enrollee cannot safely operate the PMD being requested. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre reader. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the enrollee is unable to monitor their 
blood sugars and will highly benefit from using the Freestyle Libre to better control their diabetes. The Plan 
denied your request. The Plan says the enrollee is not on insulin and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre reader.