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

 
We decided that the Plan does not have to pre-approve a Lymphapress 4-chambered pneumatic compression 
device from an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON Lymphapress. You say that you are the only provider who can 
supply a Lymphapress, which is a 4-chambered pneumatic compression device. The Plan denied your request. 
The Plan says they have in-network providers who can supply an adequate pneumatic compression device to 
meet the enrollee's medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that plans may specify the network of providers from whom 
enrollees may obtain services but must arrange for specialty care outside of the plan provider network when 
network providers are unavailable or inadequate to meet an enrollee's medical needs. 
 
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 OON Lymphapress. Our reviewer 
says that the requested item provided by an OON provider is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic venous insufficiency causing 
secondary lymphedema. On January 28, 2022, it is documented that the enrollee continues to have issues with 
lower extremity edema. The plan was to increase her Lasix dose and to order a Lymphapress to see if this 
might help her additionally. There is insufficient evidence to support that a 4-chamber pneumatic compression 
device is superior to a 3-chamber pneumatic compression device. There is no evidence that the 3-chamber 
pneumatic compression device would be inadequate in meeting the enrollee's medical needs. 
 
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 OON Lymphapress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Lymphapress 4-chambered pneumatic compression device from an out of 
network (OON) provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The enrollee has no acute medical problems, is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. At the current level of function with an uncomplicated below knee amputation, the 
enrollee's rehab can be safely provided at a lower intensity and alternate setting. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on August 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
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 definitive drug testing, 22 or more classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of testing of 22 or more drug classes. 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 pay for the definitive 
drug testing rendered on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on October 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97110 is not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 
 
 We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 pay for the physical therapy services rendered on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on heart (00560) provided on 
December 1, 2021. 
 
You asked the Plan to pay for anesthesia for procedures on heart (00560). You say that the patient had two 
surgeries that required anesthesia in one day and modifier 78 was billed on the second procedure. You say that 
the attached documentation should be reviewed, and the claim processed for payment. The Plan denied your 
request. The Plan says modifier 78 is only allowed to be billed along with surgical codes. 
 
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 00560 is anesthesia for procedures on heart, pericardial 
sac, and great vessels of chest; without pump oxygenator. 
 
We find that CPT code 00560is not supported in the medical record. Specifically, modifier 78 may only be 
reported with the surgery procedure code. Based on this information, we decided that Medicare rules for 
coverage of anesthesia for procedures on heart (00560) have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia for procedures on heart (00560) provided on December 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on September 
22, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
the services rendered were medically necessary and rendered in good faith. The Plan denied your request. The 
Plan says there is not a referring physician on the claim, 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90832) provided on September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve the SNF stay. You say that the enrollee needs skilled nursing services as 
soon as possible. The Plan denied your request. The Plan says the Skilled Nursing Facility (SNF) services you 
are requesting do not meet the requirements for approval. 
 
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 the SNF stay. Our reviewer says that 
the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 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 SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a skilled nursing facility (SNF) stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from July 30, 2021, to August 1, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the diagnosis code is 
supported. The Plan denied your request. The Plan says the billing of principal diagnosis code, I16.1 
hypertensive emergency, is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, I16.1, defined as 
hypertensive emergency. 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 an additional amount 
for the inpatient care. Our reviewer says that the billing of the principal diagnosis code is not supported. Our 
physician reviewer found the provided documentation does not support the billing of the principal diagnosis 
code, I16.1, hypertensive emergency.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for the acute inpatient hospital care provided from July 30, 2021, to August 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aloxi (J2406). 
 
You asked the Plan to pre-approve Aloxi. You say that the requested drug is necessary. The Plan denied your 
request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aloxi. Our reviewer says that the 
requested drug, Aloxi, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for prophylaxis in the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the prophylactic use 
of the requested drug in the enrollee's specific clinical situation. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Aloxi (J2406).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a dual-energy X-ray absorptiometry bone density study (77080) 
provided on April 9, 2021. 
 
You asked the Plan to pay for an X-ray bone density study. You say that the provided records substantiate the 
service at issue. The Plan denied your request. The Plan says that rules for payment have not been met because 
the available records do not support the service 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 77080 is "Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton 
(eg, hips, pelvis, spine)." 
 
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 an X-ray bone density study. Our reviewer says that the 
service at issue meets criteria for reimbursement. Our reviewer found that the enrollee on April 9, 2021, had a 
DEXA scan which is documented by report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an X-ray bone density study have been met. Therefore, we decided that the Plan 
has to pay for a dual-energy X-ray absorptiometry bone density study (77080) provided on April 9, 2021.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on July 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport is covered to the nearest 
appropriate facility. 
 
We looked at the file and Medicare rules. The file shows that the transport was not completed to the nearest 
appropriate facility. Therefore, we decided that the Plan does not have to pay for the ambulance transport 
rendered on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210), removal of residual tooth 
roots (D7250), and alveoloplasty in conjunction with extractions (D7310) provided on July 12, 2021. 
 
You asked the Plan to pay for the surgical extractions, removal of residual tooth roots, and alveoloplasty. You 
say that at no time were you told that you were only allowed two extractions per year. The Plan denied your 
request. The Plan says your benefits for these services have been satisfied and the frequency limitations have 
been exceeded. 
 
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, extractions and oral surgery services 
are each limited to two procedure codes per calendar year. The record shows that you received two simple 
extractions (D7140), a removal of residual tooth roots (D7250), and alveoloplasty in conjunction with 
extractions (D7310) on July 12, 2021 which were covered by the Plan at the in-network benefit rates, and your 
extractions and oral surgery benefits have been exhausted. Therefore, we decided that the Plan does not have to 
pay for the surgical extractions (D7210), removal of residual tooth roots (D7250), and alveoloplasty in 
conjunction with extractions (D7310) provided on July 12, 2021.  
 
Your complaint about being upset with the Plan's coverage is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 18, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim was denied in 
error. You also say that the enrollee was an inpatient on the date of service in this case and not enrolled in 
hospice. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care (99223) provided on October 18, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on November 4, 2021. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
the dental office is refunding the amount that the Plan paid for the immediate dentures. You also say that you 
would like to be reimbursed what you paid for the complete dentures. The Plan denied your request. The Plan 
says your benefits for these services have been satisfied and the frequency limitations have been exceeded. 
 
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, complete dentures and immediate 
dentures share a frequency limitation of one upper complete and/or one lower complete denture every five 
years. The record shows that you received a maxillary immediate denture (D5130) and mandibular immediate 
denture (D5140) on February 19, 2021 and your complete dentures and immediate dentures benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture 
(D5110) and complete mandibular denture (D5120) provided on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orenitram ER tablets. 
 
You asked the Plan to pre-approve Orenitram ER tablets. You say that the enrollee will most likely die without 
this medication. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition by their Medicare Part B plan. 
 
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 Orenitram ER tablets.  
 
Benefits for Orenitram ER tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5267) and procedure (A9270), provided on 
August 5, 2021. 
 
You asked the Plan to pay for the hearing services. You say that the service should be covered. The Plan denied 
your request. The Plan says you did not obtain this service through the Plan's hearing vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained through the Plan's preferred brand.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the hearing aid (V5267) and procedure (A9270), provided on August 5, 2021.