Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CardioMEMs device. 
 
You asked the Plan to pay for the CardioMEMs device. 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 pay for the CardioMEMs device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a lack of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in 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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pay for the CardioMEMs device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 lab services provided on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, although there are no pulmonary function tests to confirm and assess severity. There was CO2 retention 
during a recent hospitalization, with PaCO2 of 67. He may have chronic CO2 retention due to a combination of 
COPD and obesity-hypoventilation syndrome. If so, he may benefit from ventilatory support during sleep with 
bipap, in the AVAPS mode. But Medicare does not cover a home ventilator when used 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that you need this scan before your cancer spreads. 
The Plan denied your request. The Plan says that PET scans are not considered reasonable or medically 
necessary for initial treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that a 
PET scan is not medically reasonable and necessary. You have unfavorable intermediate prostate cancer. An 
initial PET cannot be covered for staging. Our physician reviewer found that your condition does not meet 
criteria for coverage of a PET scan. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis (L1690) provided on March 3, 2022. 
 
You asked the Plan to pay for a hip orthosis. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical documentation does not discuss the item at issue. 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 a hip orthosis (L1690) provided on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power wheelchair (PWC) to be provided by an 
out-of-network (OON) supplier. 
 
You asked the Plan to pre-approve the OON PWC. You say that the physician wishes to use the OON provider 
due to poor experiences with other suppliers. In addition, some network providers do not have the type of PWC 
the enrollee needs. The Plan denied your request. The Plan says it was confirmed that at least one nearby 
supplier is able to provide the type of PWC required. There is no clear reason that an OON provider is needed 
in this case. 
 
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 new power wheelchair (PWC) to be provided by an out-of-network (OON) supplier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a bone replacement 
graft (D7953), provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an endosteal implant and a bone replacement graft. You say that you were 
told to get a second opinion. The Plan denied your request. The Plan says services must be provided by a 
participating provider. 
 
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. The Plan covers covered 
dental benefits when they are provided by a participating provider.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of an endosteal implant and a bone replacement graft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a bone 
replacement graft (D7953), provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an annual wellness visit. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the rendering provider is non-participating and there is not a 
referring provider. The Plan also says that there is no evidence that this is urgent or emergent. 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on March 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that they have also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast lift surgery. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is 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 the procedure. Our reviewer says that 
breast lift surgery is not medically reasonable and necessary in this case. Our reviewer found that the record 
indicates that the enrollee has macromastia. The record provided does not indicate that the enrollee has 
intertrigo refractory to conservative management. The record indicates that the enrollee is receiving treatment 
or other known etiologies of her back, neck, and shoulder pain. The record suggests that the requested service 
is to alter appearance.  The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules,  of the requested service. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast lift surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital hearing aid (V5261) provided on September 26, 
2021 by an out-of-network (OON) provider 
 
You asked the Plan to pay for the digital hearing aid. You say that due to your poor experience with the Plan's 
hearing aid vendor, you went to a hearing aid provider closer to your home. You also say that when the Plan's 
selected provider does not provide a complete service, the Plan should stand behind their customers allowing 
them to find someone that will help them, and you believe you should be reimbursed. The Plan denied your 
request. The Plan says you received this service from a provider who is not a part of the Plan's vendor network. 
The Plan also says that you did not contact the Plan prior to receiving this service to verify benefits or access 
your hearing aid benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by a Plan approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the digital hearing aid have not been met. Therefore, we decided that the Plan does not have to pay 
for the digital hearing aid (V5261) provided on September 26, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications 
established in the applicable LCD. 
 
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 injections. Our reviewer says that 
the requested facet joint injections are medically reasonable and necessary. Our physician reviewer found that 
the enrollee has been doing an at-home exercise program. This fulfills the criteria of conservative therapy. The 
procedure is 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 injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on March 1, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 76705 is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76705) provided February 18, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 
not eligible for separate payment.  
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 76705 
shares a bundled relationship with code 93976. 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 an ultrasound (76705) provided February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) and 
gingival irrigation (D4921), provided by a participating provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing and gingival irrigation. You say that 
these services are medically necessary. The Plan denied your request. The Plan says the requested services 
have been correctly denied. 
 
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. The Plan covers one 
periodontal scaling and root planing every two years. The Plan does not cover a gingival irrigation. 
 
We looked at the file and Medicare rules. D4342 was previously provided on May 13, 2021. Based on this 
information, we decided that the Plan's rules for coverage of periodontal scaling and root planning have already 
been met and exhausted. Gingival irrigation is not a covered dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve periodontal scaling and root planing (D4342) and gingival irrigation (D4921), 
provided by a participating provider.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with stand-by assistance and is supervision/stand-by assist for 
transfers. Provided records do not document a significant decline in the enrollees functional status to 
necessitate daily inpatient skilled therapy services. There is no documentation that the enrollee requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
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 pay for an x-ray of the hand (73130) provided to the enrollee on 
December 8, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says the claim is missing an anatomical modifier. 
 
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 73130 is "Radiologic examination, hand; minimum of 3 
views." 
 
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 x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that no radiology report can be found in 
the records. 
 
 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 x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for an x-ray of the hand (73130) provided to the enrollee on December 8, 2021.