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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that your condition is pulmonary fibrosis and a 
bacterial infection that has colonized into your lungs with extreme mucus production all in your bronchial tubes 
and now in your lungs. The device is medically necessary for your conditions. The Plan denied your request. 
The Plan says you have a history of bronchiectasis but do not have a history of a daily productive cough for at 
least six continuous months or frequent exacerbations requiring antibiotic therapy. You do not meet criteria for 
approval of this device. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found medical records document evidence of 
bronchiectasis on imaging, but the records do not document a daily productive cough for at least six (6) 
continuous months; or frequent exacerbations requiring antibiotic therapy, as required by the Local Coverage 
Determination (LCD) L33785. Provided medical records do not document you presently use a mechanical 
insufflation device and plan to continue to do so. Records document persistent secretions despite multiple 
nebulizers daily but records available to this reviewer do not document failure of guaifenesin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult sized disposable incontinence product, brief/diaper 
(T4524). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are having difficulty controlling 
your bladder and you are using two or three a day which is a little costly. The Plan denied your request. The 
Plan says Medicare and the Plan do not cover incontinence supplies because they are disposable, non-reusable 
hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult sized disposable 
incontinence product, brief/diaper (T4524).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat echocardiography services. 
 
You asked the Plan to pre-approve the repeat echocardiography services. You say that the enrollee needs to 
have a complete two-dimensional (2D) echo with the cardiology department for the five month follow up from 
their last echo. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular stress testing would not be considered 
reasonable and necessary when the incremental information obtained from a repeat test or from the addition of 
an echocardiogram to electrical stress test is of no clinical relevance. 
 
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 repeat echocardiography services. 
Our physician reviewer found the enrollee has a history of chronic pericardial effusion. Our reviewer found the 
documentation at this time would not point to a change in status that would support the medical necessity of a 
repeat transthoracic echocardiogram (TTE). Clinical guidelines do not support repeating a TTE with no 
intervening change in clinical status or new signs, symptoms or physical findings. Our physician reviewer also 
found that there is no supportive evidence for the medical necessity of repeat TTE in this this enrollees 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 the repeat echocardiography services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat echocardiography services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you need 
the Dexcom to check your sugar levels. The Plan denied your request. The Plan says you do not require insulin 
three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
February 15, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $150 copayment for an outpatient hospital visit. This item/service falls within the 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
outpatient hospital visit provided on February 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 23, 2022 to 
March 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 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 February 23, 2022 to 
March 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 18, 2022, to 
April 16, 2022. 
  You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the NOA was 
not received, and this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date will 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As more than 30 days passed between the timely filing date 
and when the NOA should have been received, no payment can be made on this claim. Therefore, we decided 
that the Plan does not have to pay for home health services provided from March 18, 2022, to April 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628,64629). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are 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 an intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental and more research is needed to show its safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628,64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 16, 2022, to 
January 20, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
clinical evidence supports the diagnosis codes and payment at the originally billed DRG should be approved. 
The Plan denied your request. The Plan says the records do not support diagnosis codes N17.0 and J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.0, defined as acute renal failure 
with tubular necrosis and J96.01, defined as acute respiratory failure, with hypoxia. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the documentation does not meet the criteria for coverage. Our physician reviewer found that 
acute renal failure and respiratory distress were not documented until the discharge note. Therefore, the 
diagnosis codes are not supported in the medical record 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 16, 2022, to January 20, 2022, at the DRG originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on August 08, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately billable. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on August 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services (99233) provided from July 
18, 2022, to July 20, 2022. 
 
You asked the Plan to pay for hospital care. You say that this was a cardiology follow-up which was medically 
necessary. These are the only services submitted for these dates of service. The Plan denied your request. The 
Plan says the payment for these services is included in the global surgery payment for procedure code 33249, 
which has a 90-day global surgery period and was performed by this cardiology department for the enrollee on 
June 27, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that preoperative visits, intra-operative services, 
complications following surgery, postoperative visits, postsurgical pain management, supplies (except for those 
identified as exclusions) and miscellaneous services provided within the global surgery period of a service are 
included in the global surgery package rate. Modifiers were established to simplify billing for visits and other 
procedures which are furnished during the postoperative period of a surgical procedure, but which are not 
included in the payment for the surgical procedure.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital care have not been met. Specifically, the record shows that the enrollee received insertion 
or replacement of permanent implantable defibrillator system (33249) on June 27, 2022. This service has a 90-
day global surgery period. The services at issue were not billed with a modifier to indicate that they are not 
related to this service and therefore not included in this package. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care services (99233) provided from July 18, 2022, to July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 11721. The Plan denied your request. The Plan says payment for 
code 11721 is bundled into payment for code 11055. 
 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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on June 29, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and accessory provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with upgraded electronics 
power leg lifts and attendant control coded as K0861, E0950, E0953, E1007, E1012, E1028, E2311, E2313, 
E2323, E2331, E2363, E2377, E2607 and E2615. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee feels that you need the 
wheelchair because of the MS that is progressing. The Plan denied your request. The Plan says the enrollee 
does not have medical need for multiple power options included with K0861 group 3 power wheelchair. The 
upgraded electronics cannot be covered as it is not medically necessary to control the three requested power 
options through the joystick. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has MS (multiple sclerosis) and is non ambulatory. As the record 
explicitly states the enrollee is able to use a standard joystick. The enrollee does not require power elevating leg 
rests and does not require power tilt and recline as the enrollee has been in a wheelchair for over a year and 
does not have skin issues. The enrollee is continent, able to weight shift and is not at high risk for skin 
breakdown. The enrollee does not use a catheter and does not have significant spasticity. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair with upgraded electronics power leg lifts and 
attendant control coded as K0861, E0950, E0953, E1007, E1012, E1028, E2311, E2313, E2323, E2331, 
E2363, E2377, E2607 and E2615.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on June 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says the device is not payable for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  The item at issue in this appeal was used at an ambulatory surgical center.  Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device and related supplies provided on June 24, 2022.
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 July 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that these 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 July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has these done every year. 
The Plan denied your request. The Plan says diagnostic facet procedures must be repeated. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
 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 services. Our physician 
reviewer found that the enrollee has chronic axial low back pain. The prior lumbar facet ablation procedure was 
three years ago. No recent successful (minimum 80% relief) diagnostic lumbar medial branch facet nerve 
blocks have been completed within the past three years. Coverage criteria states that if the last RFA procedure 
was more than two years ago, then diagnostic facet procedures must be repeated. Therefore, at this point, the 
request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.