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

 
We decided that the Plan does not have to pay for the home health services provided between October 8, 2021, 
and November 5, 2021. 
 
You asked the Plan to pay for the home health services. You say that the signature and date on the original plan 
of care were smeared and illegible. However, you have submitted a corrected plan of care signed by the 
physician. The Plan denied your request. The Plan says the documentation does not support that there was a 
signed plan of care for the episode at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that a signed and dated plan of care must be on file 
prior to submitting the final claim for an episode of home health care.  
 
We looked at the file and Medicare rules. The documentation does not show that a signed/dated plan of care 
was present for this 30-day episode. Based on this information, we decided that Medicare rules for coverage of 
the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided between October 8, 2021, and November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access (76937) and the 
injection of non-compounded foam sclerosant (36465) provided on October 20, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the ultrasound guidance and injection. You say that you were not told that this 
provider was out-of-network. The Plan denied your request. The Plan says the services were provided out-of-
network and were not 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 the ultrasound guidance for vascular access 
(76937) and the injection of non-compounded foam sclerosant (36465) provided on October 20, 2021, by an 
out-of-network (OON) 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, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. You are walking household distances with a 
wheeled walker with contact guard assistance and is contact guard assist for transfers. Provided records do not 
document a significant decline in your functional status to necessitate daily inpatient skilled therapy services. 
You do not require 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 30, 2022, through February 28, 2022. 
 You asked the Plan to pay for the SNF services rendered. You say that it is felt that Medicare payment should 
be made for these services. The Plan denied your request. The Plan says there were no daily skilled needs 
during this time period. 
 
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 pay for the SNF services rendered. Our reviewer 
says that the SNF care provided was not medically reasonable and necessary. Our physician reviewer found the 
beneficiary is a female with schizophrenia, chronic kidney disease, and a recent aspiration event, treated with 
intramuscular antibiotics. From a nursing perspective, the beneficiary received oral medications. The 
beneficiary had stable vital signs. She was monitored for falls. Regarding rehabilitation services, the 
beneficiary received physical, occupational, and speech therapy. The beneficiary was at a contact guard assist 
level for functional mobility. She tolerated a ground diet and thin liquids.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require skilled therapy services on a daily basis. This beneficiary does not meet severity 
of illness or intensity of service criteria for 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 the SNF services rendered have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 30, 2022, 
through February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device (E1399). 
 
You asked the Plan to pre-approve a Volara system-high frequency oscillation lung expansion device. You say 
that the enrollee has tried and failed flutter valve therapy. The enrollee requires oscillatory and lung expansion 
therapy to help with secretion clearance. The Plan denied your request. The Plan says this device is not a 
covered benefit because there is no data to support that this device is effective and additionally, is not covered 
for use in the home. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Volara system-high frequency 
oscillation lung expansion device. 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 bronchiectasis 
and pulmonary infection with MAI.  Airway clearance therapy is an important component of treatment.  
However, the Volara system has not been shown to be effective in the outpatient treatment of chronic lung 
disease. This treatment incorporates airway pulse oscillation, nebulization, and end-expiratory positive 
pressure. There is no evidence it is superior to a flutter valve or chest wall oscillation in airway clearance, or 
that combining these components adds benefit. 
 
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 Volara system-high frequency oscillation lung expansion device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system-high frequency 
oscillation lung expansion device (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Test Strips. 
 
You asked the Plan to pre-approve Contour Next Test Strips. You say that you need test strips to check your 
blood sugar. You are not sure how to proceed with this denial. The Plan denied your request. The Plan says you 
do not meet exception criteria for coverage of a non-preferred brand of testing supplies. 
 
 
 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Contour Next Test Strips have been 
met. Specifically, the documentation submitted does not include any clinical information to verify that you 
have tried and failed the Plan's preferred brands or that the Plan's preferred brands would be contraindicated for 
you. Therefore, we decided that the Plan does not have to pre-approve Contour Next Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is considered not 
medically necessary because coverage criteria are not met. This patient has amyotrophic lateral sclerosis 
(ALS), a generalized progressive neuromuscular disease, and the enrollee may well require a home ventilator in 
the future. He currently has bulbar symptoms, with swallowing difficulty. But the clinical note of June 15, 2022 
(addendum) indicates spirometry is normal, although no date of the test is provided. There are no results of supine spirometry or maximum mouth pressures, and no results of overnight oximetry or capnography. It 
appears the enrollee does not yet need a ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve all lower extremity prosthesis, shank foot system with vertical 
loading pylon (L5987), all lower extremity prostheses, multi- axial rotation unit (L5986), an addition, 
endoskeletal system, below knee, flexible protective outer surface covering system (L5962) and an addition to 
lower extremity, below knee, molded supracondylar suspension (L5670). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested prosthetics are medically necessary. 
The Plan denied your request. The Plan says that the requested prosthetics do not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the current prosthesis is noted to be poor fitting and he is wearing approximately 12-15 ply 
socks (resulting in pistoning and rotation in the socket). He demonstrates significant physiological changes in 
shape and size of the right below the knee residual limb. He has significant atrophy of the right residual limb 
(that has resulted in bony prominences requiring additional prosthetic attention to unload those areas to avoid 
discomfort and future skin irritations). This increases the potential for further injury. The outer covering is for 
protection, allows for easy cleaning, and allows him to wear in water. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve all lower extremity prosthesis, shank foot system with vertical loading pylon (L5987), all lower 
extremity prostheses, multi- axial rotation unit (L5986), an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962) and an addition to lower extremity, below knee, molded 
supracondylar suspension (L5670).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) services provided during an 
emergency room visit on December 10, 2021, billed with code 93042. 
 
You asked the Plan to pay for the ECG as billed. You say that this should be paid in full. The Plan denied your 
request. The Plan says payment for 93042 is included in payment for the emergency room visit. 
 
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 93042 is Rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
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 ECG as billed. Our reviewer says that the documentation 
does not support separate payment for the ECG. Our reviewer found the medical record does not support ECG 
was not performed by a monitoring system with telemetry monitor strip. Therefore, interpretation and report cannot be verified, as this is performed by the monitoring system. The documentation also did not include a 
separate, signed, written report for the ECG. An ECG would be considered part of the work up and treatment of 
the patient in the emergency department and would not be considered a separate charge. 
 
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 ECG as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the electrocardiogram (ECG) services provided during an emergency room visit on 
December 10, 2021, billed with code 93042.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a group 3 heavy duty, multiple power 
option, power wheelchair and accessories (K0862, E2311, E2363, E1028, E1002, E0955, E1012, E2608). 
 
You asked the Plan to pre-approve replacement of a group 3 heavy duty, multiple power option, power 
wheelchair and accessories. You say that the enrollee is seated in his wheelchair for 8+ hours each day and has 
impaired lower extremity sensation that makes him a very high risk for skin breakdown. The tilt function on his 
current wheelchair is no longer working and in turn leaves him with no way to safely relieve pressure. You are 
requesting reconsideration. The Plan denied your request. The Plan says the enrollee does not have a qualifying 
diagnosis causing mobility limitation for which a group 3 power wheelchair is medically needed. As the base 
code for the requested wheelchair is not reasonable and necessary, none of the requested accessories can be 
approved. 
 
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. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve 
replacement of a group 3 heavy duty, multiple power option, power wheelchair and accessories (K0862, 
E2311, E2363, E1028, E1002, E0955, E1012, E2608).
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 the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee is functioning with supervision. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs can, as a practical matter, be provided at a lower level of 
care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided from April 21, 
2021, to January 25, 2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the supplies should be billed 
as in-network. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for prosthetic devices and related supplies, including ostomy supplies. 
 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Skin Barrier (A4407)  April 21, 2021 $204.00 $40.80 
Skin Barrier Solid (A4385)  April 21, 2021 $118.60 $23.72 
Ostomy Pouch (A4432)  April 21, 2021 $83.60 $16.72 
Skin Barrier Solid (A4385)  May 24, 2021 $118.60 $23.72 
Skin Barrier (A4362)  May 24, 2021 $68.60 $13.72 
Skin Barrier (A4407)  August 31, 2021 $204.00 $40.80 
Ostomy Pouch (A4432)  August 31, 2021 $83.60 $16.72 
Skin Barrier Solid (A4385)  August 31, 2021 $118.60 $23.72 
Ostomy Pouch (A4432)  January 25, 2022 $87.80 $17.56 
Skin Barrier (A4407)  January 25, 2022 $214.40 $42.88 
Skin Barrier Solid (A4385)  January 25, 2022 $124.60 $24.92 
Total:  $285.28 
 
You have been asked to pay a total of $285.28, which is 20% of the allowed amount for the ostomy supplies. 
The ostomy supplies fall within the Prosthetic Devices and Related Supplies 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 coinsurance for ostomy supplies provided from April 21, 2021, to January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded as 81206, 81292 and 81301 
provided August 24, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that this letter documents the medical necessity 
of the test requested for the enrollee to assist i the treatment, prognosis and diagnosis of their cancer. The Plan 
denied your request. The Plan says the services does not meet Medicare NCD/LCD criteria. 
 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 CPT code 81206, 81292 and 81301 is not supported in the medical record. 
Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing coded as 81206, 81292 and 81301 provided August 24, 2021.