Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93975 for date of service April 22, 2022. 
 
You asked the Plan to pay for procedure code 93975. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 93975 is duplex scan of arterial inflow and venous 
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study. 
 
We find that CPT code 93975 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation to support a duplex scan of arterial inflow and venous outflow of 
abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study; therefore, code 93975 cannot 
be verified.  Based on this information, we decided that Medicare rules for coverage of procedure code 93975 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 93975 for date of service 
April 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient physician's services provided on August 19, 2022. 
 
You asked the Plan to pay for the inpatient physician's services. You say that the insured was already a patient 
in the hospital at the time of these services. The Plan denied your request. The Plan says that this service was 
not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Plan rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for inpatient physician's services 
provided on August 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 3, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the denial and request 
reconsideration. You also say you have attached medical records for review. The Plan denied your request. The 
Plan says the requested service lacks information which is needed for adjudication. 
 
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 find that CPT codes 82306, 86334, 86696, 86665, 83521, 86645, 84443, 82232, 86664, 86678, 86777, 
86644, 86695, 86787, 84165, 80053, 82784, 85025, 83735, 83615, 82248, 84100, 84550, 84155, 85652 are not 
supported in the medical record. Specifically, the Plan needs a description of service. A corrected claim was 
requested and not received. Based on this information, we decided that Medicare rules for coverage of 
laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on October 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid is required before alternatives can be considered. 
 
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 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 Xgeva. Our reviewer says that Xgeva is 
not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve impression and custom preparation; oral surgical splint, 
arthroscopy, temporomandibular joint, surgical and anesthesia for intraoral procedures, including biopsy; not 
otherwise specified. 
 
You asked the Plan to pre-approve impression and custom preparation; oral surgical splint, arthroscopy, 
temporomandibular joint, surgical and anesthesia for intraoral procedures, including biopsy; not otherwise 
specified. You say that the services are medically necessary. The Plan denied your request. The Plan says the 
temporomandibular joint syndrome (TMJ) procedures are not a covered benefit. 
 
The Plan contract says that dental splints, dental prosthesis, or any dental treatment for the teeth, gums, or jaw 
or dental treatment related to temporomandibular joint syndrome (TMJ) are not covered under any condition.  
 
We looked at the file and Plans rules. Based on this information, we decided that Plans rules for coverage of 
impression and custom preparation; oral surgical splint, arthroscopy, temporomandibular joint, surgical and 
anesthesia for intraoral procedures, including biopsy; not otherwise specified have not been met. Therefore, we 
decided that the Plan does not have to pre-approve impression and custom preparation; oral surgical splint, 
arthroscopy, temporomandibular joint, surgical and anesthesia for intraoral procedures, including biopsy; not 
otherwise specified.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an observation or inpatient hospital care, for the evaluation 
and management of a patient including admission and discharge on the same date provided July 19, 2022, 
billed with procedure code 99236. 
 
You asked the Plan to pay for the evaluation. You say that the services were medically necessary. The Plan 
denied your request. The Plan says procedure code 99236 is not supported by the records. 
 
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 99236 is an observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our physician 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 evaluation. Our reviewer says that the documentation 
does not support procedure code 99236. Our reviewer found that the medical decision making was not of high 
complexity.   
 
We looked at this physicians review, the file, and Medicare rules. In terms, 99236, the record does not contain 
evidence that a evaluation was performed. Based on this information, we decided that Medicare rules for 
coverage of the evaluation have not been met. Therefore, we decided that the Plan does not have to pay for an 
observation or inpatient hospital care, for the evaluation and management of a patient including admission and 
discharge on the same date provided July 19, 2022, billed with procedure code 99236.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 13, 2022, and 
December 14, 2022. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says 
Medicare does not pay for this service. 
 
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 pay for self-administered drugs provided 
on December 13, 2022, and December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2022, billed with 
codes 95816 and 95911. 
 
You asked the Plan to pay for the services as billed. You say that these services were billed correctly. The Plan 
denied your request. The Plan says the billed services are 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 95816 is electroencephalogram (EEG); including 
recording awake and drowsy. Code 95911 is defined as nerve conduction studies; 9-10 studies. 
 
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 as billed. Our reviewer says that the documentation does not support the billed codes. Our reviewer found for code 95816, the procedure report does 
not document drowsiness or sleep to support this code. The medical record also does not include 
documentation of nerve conduction studies for date of service 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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on August 5, 2022, billed with codes 95816 and 95911.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E00466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for continued coverage of a home mechanical ventilator that is 
not being used by the enrollee is not covered. The enrollee's documented failure to utilize the ventilator 
constitutes evidence to support discontinuation of the rented equipment. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, severe obesity, and obstructive sleep apnea. The enrollee was prescribed a home ventilator in July 
2022, after a hospitalization for exacerbation of congestive heart failure and COPD. A device download 
covering July 7, 2022, to November 2, 2022, shows the device was used for at least 4 hours/day for 0% of days. 
There is also no evidence that BiPAP has been tried and failed as an outpatient.  This enrollee is not using the 
device enough to be effective. In addition, Medicare does not cover a home ventilator when used at settings 
that can be provided with BiPAP. 
 
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 (E00466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are having knee 
replacement surgery and feel that you need the item requested to prevent blood clots. The Plan denied your 
request. The Plan says the requested device is not covered under any condition. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the requested Aranesp is 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 Aranesp. Our reviewer says that the 
requested Aranesp is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has Acute myeloblastic leukemia, a myelogenous condition. The noted diagnosis is excluded by rule. 
The elements of the coverage criteria are not satisfied. The requested service is not 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say the enrollee believes all the necessary information was 
not available at the time of the initial review. You would like reconsideration based on the records submitted. 
The Plan denied your request. The Plan says the requested IRF admission is not considered reasonable and 
medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cough stimulating device, alternating positive and 
negative airway pressure (E0482). 
 
You asked the Plan to pre-approve a cough stimulating device. You say that you have pulmonary disease and 
you get a lot of mucus. You need the assistance of the device to get the mucus out. The Plan denied your 
request. The Plan says there is no evidence or clinical documentation indicating that you have a neuromuscular 
disease that has caused a significant impairment to your chest wall and/or diaphragmatic movement and an 
inability to clear retained secretions. A mechanical in-exsufflation device is not considered reasonable and 
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 a cough stimulating device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have COPD and recurrent pneumonia, with a recent hospitalization for 
empyema and decortication. There is no evidence in the medical record for neuromuscular disease or weakness 
of the respiratory musculature impairing the clearance of secretions. 
 
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 cough stimulating device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cough stimulating device, alternating positive and negative airway pressure 
(E0482).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on November 30, 2022. 
 
You asked the Plan to pay for the walker. You say that this walker is needed for your transition from a 
wheelchair and continued therapy. You said that you used this particular supplier because this item was cheaper 
than local medical supply companies. The Plan denied your request. The Plan says you purchased this item 
from a supplier who is not enrolled in Medicare, so this item cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker you purchased on November 
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
May 7, 2022, to May 26, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that you have outlined in this 
appeal how this enrollee's medical necessity actually meets the guidelines that qualify for coverage. The Plan denied your request. The Plan says you are requesting reconsideration based on medical necessity for this 
enrollee and evidence based medical literature that substantiate the efficacy of the treatment rendered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided May 7, 2022, to May 26, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued care in a 
long-term acute care setting for respiratory failure and pulmonary disease. The Plan denied your request. The 
Plan says admission to a long-term acute care hospital does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.