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

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 May 26, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev. 
 
You asked the Plan to pre-approve Ofev. You say that you have provided medical records to support approval 
of this drug. The Plan denied your request. The Plan says this drug is not covered under the patient's medical 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ofev.  
 
Benefits for Ofev may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device identified with code 
E0651 and full leg garments identified with code E0667. 
 
You asked the Plan to pre-approve a pneumatic compression device and full leg garments. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested items. 
 The Plan follows Medicare rules. Medicare rules say that PCDs are only covered for certain 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 a pneumatic compression device and 
full leg garments. Our reviewer says that the documentation does not support that the requested items are 
medically reasonable or necessary. Our physician reviewer found you have a diagnosis of lymphedema, not 
elsewhere classified. The Venous Institute note dated July 13, 2022, documents that you have been wearing 
graduated compression stockings over the last six to seven years but continue to have leg swelling and 
discomfort. It is documented that you have used non-steroidal anti-inflammatory drugs for leg symptoms, leg 
elevation for at least six weeks, and have lost weight. Despite conservative treatment, you are experiencing 
symptoms that affect your affairs of daily living. While the documentation shows that you have a diagnosis of 
lymphedema, the documentation does not support that you have marked hyperkeratosis with hyperplasia and 
hyperpigmentation, papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with 
persisting lymphorrhea, or detailed measurements over time confirming the persistence of the lymphedema 
with a history evidencing a likely etiology. Therefore, you do not meet criteria for the requested items. 
 
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 pneumatic compression device and full leg garments have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device identified 
with code E0651 and full leg garments identified with code E0667.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted documentation was reviewed and only shows one procedure performed on this 
date of service. 
 
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 01470 is "Anesthesia for procedures on nerves, muscles, 
tendons, and fascia of lower leg, ankle, and foot; not otherwise specified." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports CPT 
01472 (41 units) was paid on claim KLC 43456124-0. The procedure report was not found in documentation to 
support anesthesia services to verify correct procedure code and units billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided on January 29, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you have multiple health issues and you have fallen 
before. You said that you need assistance getting into and out of chairs. The Plan denied your request. The Plan 
says that SNF care is not medically necessary and your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found although you do not have documented skilled nursing needs, you do have 
documented skilled therapy needs.  You are functioning below your baseline, having recently been hospitalized 
twice. You are at risk for falls and injury due to your ongoing hypoxia. Inactivity will likely make you weaker 
and may increase your clot burden.  Daily skilled services for strength training, endurance training and 
supervision/safety are medically necessary and reasonable. Daily skilled services are required to establish a 
maintenance program and/or to prevent deterioration of your condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 power scooter. 
 
You asked the Plan to pre-approve these services. You say that you can no longer drive and need to go to the 
grocery store and any personal errands. The Plan denied your request. The Plan says the services are not 
covered. 
 
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 pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided April 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 G0483 is Drug Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the physician order 
provided does not specify what drug classes are being tested for. Records do not show testing for 22 or more 
drug classes. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided April 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug validity testing billed with code 83789-91 for date of 
service August 24, 2021. 
 
You asked the Plan to pay for the drug validity testing. You say that these lab services were medically 
necessary. The Plan denied your request. The Plan says it has paid for the other codes billed on this date of 
service.  However, validity testing cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug validity testing have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for drug validity testing billed with code 83789-91 for date of service August 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265). 
 
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regeneration. You say 
that you need this service so you can eat. The Plan denied your request. The Plan says this service is not 
covered under your benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography (procedure code 75774) provided to the enrollee 
on April 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested service code is not substantiated in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that diagnostic angiography 
performed at the time of an interventional procedure is separately reportable if no prior catheter-based 
angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based 
on the diagnostic study. In this case, medical record does not include documentation to support the above 
criteria, and therefore modifier -59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography (procedure code 75774) provided to the enrollee on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ankle foot orthosis (L1960) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the orthosis. You say that you have received continuity of care with this 
provider since 2014. You feel that going with an out of network provider is medically necessary to your well- 
being and continued retention of mobility and independence. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 
the ankle foot orthosis (L1960) 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 decompression laminectomy surgery. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not contain 
documentation that you have stopped smoking. Smoking is a contraindication to the requested surgery. The 
services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve decompression laminectomy surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-
of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the Plan does not have a fellowship trained geriatrician. You say that there are nursing 
home providers who see elderly patients but no one to see patients on an outpatient basis. The Plan denied your 
request. The Plan says the services are available with in-network neurology providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee has been a non-smoker 
for 29 years. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not a current smoker or former 
smoker who quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a 
low dose computed tomography (LDCT) scan for lung cancer screening.
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 you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device 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 home ventilator. Our reviewer says 
that the documentation does not support the requested device is medically reasonable or necessary. Our 
physician reviewer found there is a listed diagnosis of chronic obstructive pulmonary disease (COPD), but 
there are no pulmonary function tests to confirm or assess severity. There are no diagnoses of thoracic 
restrictive disease or neuromuscular disease. You are on bilevel positive airway pressure (BiPAP) currently, 
but settings are not provided. Results of arterial blood gases done as an outpatient while stable are not provided. If you have severe COPD with chronic carbon dioxide retention, BiPAP in the Average volume-
assured pressure support (AVAPS) mode may be beneficial. However, Medicare does not cover a home 
ventilator when used as BiPAP. Therefore, you do 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 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: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is necessary for your condition. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The Volara OLE (oscillation and lung expansion) 
system 
 
You asked the Plan to pre-approve the Volara system. You say that this device is medically necessary as the 
patient's current high frequency chest wall oscillation device is no longer an option. The Plan denied your 
request. The Plan says there is no clear evidence to support the Volara's efficacy in cystic fibrosis (CF) patients. 
There is no recent guideline supporting use of Volara for CF over any other type of vest. In addition, there is no 
evidence showing a beneficial role for the Volara system in patient's that suffers from ascites and/or traditional 
VEST-related pain. 
 
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 the Volara system. Our reviewer says 
that The Volara System OLE (oscillation and lung expansion) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this patient has cystic fibrosis (CF) with mild lung disease 
and severe liver disease, with ascites. The ascites is creating difficulties with using the vest device for airway 
clearance. The Volara System has not been adequately studied in cystic fibrosis, and its efficacy as an airway clearance therapy has not been established.  The System includes lung expansion, which is not known to be of 
benefit in CF. The third component, nebulization, would duplicate treatment that the patient already has.   
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve The Volara OLE (oscillation and lung expansion) system