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

 
We decided that the Plan does not have to pre-approve an implantable eCoin device. 
 
You asked the Plan to pre-approve an implantable eCoin device. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention.  
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 eCoin device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found eCoin is not 
medically necessary in this case. This procedure is still considered experimental and investigational. A review 
of the current medical literature does not consider this service to be standard medical treatment. 
 
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 eCoin device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable eCoin device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on May 18, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says that this service is not supported as billed. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that at least 
15 drug classes were tested in this case, including alcohol biomarkers, amphetamines, barbiturates, 
benzodiazepines, buprenorphine, cocaine, fentanyls, heroin metabolite, methadone, opiates, oxycodone, 
phencyclidine, skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we decided that 
Medicare rules for coverage of definitive drug testing have been met. Therefore, we decided that the Plan has 
to pay for definitive drug testing (G0482) provided on May 18, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all endoskeletal lower extremity prosthesis, axial 
rotation unit, with or without adjustability (L5984) and all lower extremity prosthesis, shank foot system with 
vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve prosthetics. You say that you disagree with the denial and are requesting 
approval of the prosthetics. The Plan denied your request. The Plan says the requested prosthetics do not meet 
Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee's physician states that the enrollee 
is currently a K2 ambulator. The records also show that that the enrollee's current prosthesis was approved in 
March 2022. Medical records do not indicate that the enrollee's current foot does not meet his needs. The 
enrollee is needing a new socket which has been approved on prior review. The current foot is still under 
warranty. Based on this information, we decided that Medicare rules for coverage of prosthetics have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an all endoskeletal lower extremity 
prosthesis, axial rotation unit, with or without adjustability (L5984) and all lower extremity prosthesis, shank 
foot system with vertical loading pylon (L5987).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested ventilator is not medically necessary. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found the enrollee diagnoses of rheumatoid arthritis and chronic respiratory failure with 
pulmonary fibrosis and chronic obstructive pulmonary disease. The provided records document that the home 
ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) which could be provided 
by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support and a back-up rate. Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level 
CPAP therapy will be denied as not reasonable and necessary. Therefore, the enrollee does not meet criteria for 
the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intravenous hydration infusion (96360) and multiple 
vitamins (A9153). 
 
You asked the Plan to pre-approve an intravenous hydration infusion and multiple vitamins. The Plan denied 
your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 intravenous hydration infusion and 
multiple vitamins. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation did not support that the enrollee 
has nutrient deficiencies that require a multivitamin. Also, it was not clear that the enrollee was to have 
supervision and management of the intravenous fluids to watch for any potential complications with this 
treatment at home. Our reviewer also found that the documentation does not sufficiently support that the 
intravenous hydration plus multiple vitamins are medically reasonable and necessary or safe and effective for 
this enrollee. 
 
 
 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 intravenous hydration infusion and multiple vitamins have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an intravenous hydration infusion (96360) 
and multiple vitamins (A9153).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the lower abdomen (code 00865QX) 
provided on April 12, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the lower abdomen. You say that this claim denied 
as a duplicate in error. The Plan denied your request. The Plan says that this claim is a duplicate of a claim 
processed. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided a duplicate claim to 
substantiate their denial. Based on this information, we decided that Medicare rules for coverage of anesthesia 
for procedures on the lower abdomen have been met. Therefore, we decided that the Plan has to pay for 
anesthesia for procedures on the lower abdomen (code 00865QX) provided on April 12, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986) and a 
remote-control wristwatch to control the power assist system (K0108). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you are requesting 
reconsideration of the wheelchair and accessories due to a complete traumatic amputation. The Plan denied 
your request. The Plan says the requested accessories do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the documentation does not support that you 
are unable to self-propel an optimally configured manual wheelchair in the home to perform MRADLs or that a 
specialty evaluation was performed that documents the need for a push-rim power assist device in the home. 
The records also show that the wristwatch remote control is a non-covered item as it does not meet the 
definition of durable medical equipment under Medicare. Based on this information, we decided that Medicare 
rules for coverage of manual wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a push-rim activated power assist system (E0986) and a remote-control 
wristwatch to control the power assist system (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP device (CPT code E0601) provided from June 15, 
2022, through July 15, 2022. 
 You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says this is a duplicate claim for services that have already been paid. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The records submitted do not indicate 
that two separate services were performed/supported. This claim appears to be a duplicate for dates of service 
June 15, 2022, and July 15, 2022, that was processed and paid on September 29, 2022. Therefore, we decided 
that the Plan does not have to pay for the CPAP device (CPT code E0601) provided from June 15, 2022, 
through July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested ventilator is not medically necessary. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease unspecified. 
The provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume-assured pressure support (AVAPS) and a back-up rate. Ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy will be 
denied as not reasonable and necessary. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 81003, 82550, 82553, 82607, 82728, 
and 82746 billed for date of service April 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the services rendered. The 
Plan denied your request. The Plan says the charge is not a reasonable allowable expense. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 80053, 81003, 82550, 82553, 82607, 82728, and 82746 have a status indicator of X 
under the physician fee schedule. No payment may be made under the physician fee schedule. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 80053, 81003, 82550, 82553, 82607, 82728, 
and 82746 billed for date of service April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for a speedy recovery to 
return home. The Plan denied your request. The Plan says the services you need can be provided safely in 
another setting such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical records do show you have complex functional impairments however no 
active medical issues are documented.  Your medical needs would not be expected to require an acute hospital 
inpatient stay with rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial preventive physical examination (CPT code G0402), 
electrocardiogram (G0404) and hospital outpatient clinic visit for assessment and management of a patient 
(G0463) provided on August 10, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. You state that the facility is 
enrolled in the Medicare program to provide OTP services since January 01, 2020. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The provider did not bill as 
required by Medicare coding regulations. Multiple medical visits on the same day were reported with the same revenue center on HCPCS codes G0463 and G0402 without condition code G0 reported. Healthcare Common 
Procedure Coding System (HCPCS) code G0404 denied with reason 0992 to correct OCE edit error on other 
claim line. Therefore, we decided that the Plan does not have to pay for initial preventive physical examination 
(CPT code G0402), electrocardiogram (G0404) and hospital outpatient clinic visit for assessment and 
management of a patient (G0463) provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a second opinion with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a referral for a second opinion. You say that you feel you need a second 
opinion on your stage 4 cancer. You have lymphoma and there is something going on and you want to have it 
checked but your oncologist and your primary care physician said that you do not need a second opinion 
because your cancer is inactive. The Plan denied your request. The Plan says you must use network providers 
to get your medical care and services. The Plan also says there is appropriate care available within the Plan to 
schedule you with an in-network provider for a second opinion. 
 
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 referral for a second opinion with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone (G2067) provided on 
October 17, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. You state that the facility is 
enrolled in the Medicare program to provide OTP services since January 01, 2020. The Plan denied your 
request. The Plan says that this provider was not certified/eligible to be paid for this procedure/service on this 
date of service. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have been met. The facility where the provider rendered 
the services is enrolled with Medicare as an OTP. Therefore, we decided that the Plan has to pay for medication 
assisted treatment, methadone (G2067) provided on October 17, 2022.  
 
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.