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

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this item is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested portable ventilator is not medically 
reasonable and necessary according to Medicare coverage rules. 
 
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 requested portable ventilator is not medically reasonable and necessary. Our physician reviewer found 
this patient has COPD with exertional dyspnea. There is no CO2 retention on arterial blood gas test so the 
patient does not qualify for a ventilatory assist device. The requested ventilator (the Life2000 system) is not a true ventilator because it is not capable of providing full ventilatory support. It is intended to provide positive 
pressure oxygen during activity. There is insufficient evidence that this device is beneficial in the treatment of 
any lung disease. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
November 19, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). The Plan denied your request. The Plan 
says procedure codes 22513 and 99152 were approved. The Plan also says procedure code 99153 is not 
supported by the medical records submitted. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer as required. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services (99153) have not been met. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation services (99153) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Rhythm Electrocardiogram (ECG), 1-3 leads; 
interpretation and report only (93042) provided on October 13, 2021. 
 
You asked the Plan to pay for code 93042. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 93042 
is a column II code to column I code 29125. 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 Rhythm Electrocardiogram (ECG), 1-3 leads; interpretation 
and report only (93042) provided on October 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not require the daily skilled therapy or nursing services required 
to qualify for a skilled nursing facility admission. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sclerotherapy procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has bilateral leg pain. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is only covered under 
certain medical information.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that criteria require that sclerotherapy would only be covered if the truncal veins were either 
reflux free or previously treated. There must also be a period of 6 weeks of conservative therapy in the absence 
of truncal reflux to see if the additional sclerotherapy is necessary. Currently, the enrollee has evidence of 
truncal reflux for which treatment has been planned and approved. Coverage of further services will require a 
reevaluation of the enrollee more than 6 weeks (during which time conservative therapies are utilized and 
documented) following truncal vein ablation. The documentation does not meet criteria for coverage of 
sclerotherapy to either lower extremity. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sclerotherapy procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the cataract surgical services provided on 
August 19, 2021. 
 
You asked the Plan to waive the cost share for the cataract surgical services. You say that you would like the 
Plan to reconsider your request. The Plan denied your request. The Plan says you received cataract surgery in 
an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct cost 
share has applied per your contract with the Plan. The Plan also says that the A-C IOL (Toric) is not covered by 
Medicare or the Plan; however, you are not responsible for the amount denied for code V2787 because you 
received this service from a plan provider or based on a referral from a plan provider. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1000 deductible which applies to Outpatient surgery and a $275 
copayment once the deductible has been met.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category Outpatient 
surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 
deductible which applies to Outpatient surgery, and a $275 copayment once the deductible has been met. This 
cost sharing is a contractual obligation that had not been met at the time the cataract surgical services were 
received on August 19, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the 
cataract surgical services provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81442, 81411, 81413, 81414, 81439, 
81410, 81161, and 81286) provided on October 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal (codes 81442, 81411, 81439, 81410, 81161, and 81286), was requested solely 
for screening purposes. Medicare does not cover this test solely for screening purposes. 
 
The rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that codes 81413 and 81414 are column II codes to 
column I code 81439 with a modifier indicator of 0. The column II codes are therefore not payable. 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 laboratory services (81442, 81411, 81413, 
81414, 81439, 81410, 81161, and 81286) provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extremity venography tests (36005 and 75822) provided on 
October 5, 2021. 
 
You asked the Plan to pay for venography 36005 and 75822. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because codes 36005 and 75822 are inclusive to the primary procedure code 37238 and the record does not 
support 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 36005 and 75822 is a column II code to column I code 37238; 
however, 36005 and 75822 was billed with a modifier.  
 
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 venography 36005 and 75822. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found the procedure report does not include 
documentation to support that these were unusual non-overlapping services from the primary procedure 37238. 
Therefore, the documentation does not support the use of the -XU modifier for separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venography 36005 and 75822 have not been met. Therefore, we decided that the 
Plan does not have to pay for extremity venography tests (36005 and 75822) provided on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve SNF admission. You say that your family is unable to care for you at home. 
The Plan denied your request. The Plan says SNF level of care is not medically necessary for you currently. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF admission 
and therapy services are not reasonable or medically necessary because there is no expectation of functional 
improvement in a reasonable 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 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 the Magnetic resonance angiography (70544) provided on 
December 28, 2021. 
 You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 70544 
is a column II code to column I code 70551. 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 Magnetic resonance angiography (70544) provided on 
December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on July 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 physician services provided on July 26, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit. 
 
You asked the Plan to pre-approve a TENS unit. You say that this is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a TENS unit will not be covered for chronic low back 
pain. There are other pain indications a TENS unit will be covered for as listed 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 a TENS unit. Our reviewer says that the 
requested device is not medically reasonable and necessary. Our physician reviewer found TENS for low back 
pain is not an accepted approach based on Medicare coverage criteria. TENS for other chronic pain syndromes 
is allowed but there is not enough documentation to state that the request meets criteria.  At this point based on 
the documentation received, the request is not medically reasonable or 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 a TENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0223U) provided July 7, 2021. 
 
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 service billed is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. The testing was for 6 or more pathogens and is non-covered. 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 (0223U) provided July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia worked well in the past. The Plan denied your 
request. The Plan says you have not tried and failed treatment with one intravenous bisphosphonate therapy. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file, and Medicare rules. The Plan requires a trial of an intravenous bisphosphonate therapy, 
such as zoledronic acid. The file does not show that you have tried and failed the Plans required drugs. There 
are insufficient medical records to show that the plans required drugs would likely be less effective or likely 
have adverse effects. Based on this information, we decided that Medicare rules for coverage of Prolia have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided by a 
non-participating provider on December 2, 2021.  
You asked the Plan to pay for the determination of refractive state (92015). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is a non-
participating provider with your vision plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a participating provider with the supplemental 
vision plan. 
 
We looked at the file and the Plan's rules. The provider is not part of your supplemental vision benefit network 
of participating providers. Based on this information, we decided that the Plan's rules for coverage of the 
determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have 
to pay for the determination of refractive state (92015) provided by a non-participating provider on December 
2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the re-cement or re-bond crown 
(D2920) provided January 5, 2022. 
 
You asked the Plan to provide additional payment for the re-cement or re-bond crown. You say that dental 
treatments are related to previous radiation therapy and should be covered under your medical benefits. The 
Plan denied your request. The Plan says this service is not covered under your medical 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. The Plan covers the re-cement 
or re-bond crown with 50% coinsurance.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you were asked to 
pay $33 ($66 total cost x 50% coinsurance = $33) for the re-cement or re-bond crown. This service is not covered under your medical benefits. Therefore, we decided that the Plan does not have to provide additional 
payment for the re-cement or re-bond crown (D2920) provided January 5, 2022.