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

 
We decided that the Plan does not have to pay for codes 99220 and 99226 provided from January 17, 2022, to 
January 21, 2022. 
 
You asked the Plan to pay for codes 99220 and 99226. 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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, 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 problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
The CPT Code Manual definition of code 99226 is subsequent observation care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A 
detailed examination; 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 patient is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We find that CPT codes 99220 and 99226 are not supported in the medical record. Specifically, these 
observation evaluation and management codes require a designation of observation status. The medical records 
submitted do not indicate that the enrollee's status is designated or admitted for observation. Based on this 
information, we decided that Medicare rules for coverage of codes 99220 and 99226 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 99220 and 99226 provided from January 17, 
2022, to January 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0483) provided on May 13, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service is supported in the medical record. The 
Plan denied your request. The Plan says that the code used to report these services is not supported in the 
medical record. 
 
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 test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records support that drugs 
from 28 drug classes were tested in this case. Based on this information, we decided that Medicare rules for 
coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0483) provided on May 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee cannot tolerate bi-level positive 
airway pressure (BiPAP). The Plan denied your request. The Plan says the enrollee can be treated with BiPAP. 
 
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 requested ventilator is not medically necessary. Our physician reviewer found while the hospital 
progress notes indicate the patient did not tolerate bi-level positive airway pressure (BiPAP) in the hospital, the 
noninvasive interface is the same for BiPAP and a home ventilator. There is no evidence BiPAP has been tried, 
and failed, as an outpatient.  Medicare does not cover a home ventilator for the treatment of obesity 
hypoventilation syndrome (OHS), or 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on June 
24, 2022, to July 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
request reconsideration to review supporting documentation to further process the claim. The Plan denied your 
request. The Plan says a PCD is used in the treatment of peripheral artery disease (PAD). Other PCD codes are 
not used for this condition. The enrollee's medical record does not document a history or a diagnosis of PAD. 
 
 
 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 
pay for a pneumatic compression device (E0675) provided on June 24, 2022, to July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 98941, 97530, 97110, and 97012 billed for 
dates of service May 12, 2022, to June 9, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
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 98941, 97530, 97110, and 97012 are not supported in the medical record. Specifically, 
the records do not describe the services as billed. The records do not show that manual manipulation was 
provided to treat subluxation of the spine. Furthermore, services other than manual manipulation are not 
covered when provided by a chiropractor. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 98941, 97530, 97110, and 97012 billed for dates of service May 12, 2022, to June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that due to mitigating factors 
such as tissue mobility, tumor size, location of the lesion, prospective outcome, and potential need for 
secondary attempts to heal the cancerous lesions and local wounds, it was determined that image-guided 
superficial radiation therapy is medically necessary for this enrollee. The Plan denied your request. The Plan 
says the request does not meet the Medicare or health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general is not necessary. The decision is 
unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
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 that the records show you have low 
back pain described as stabbing and aggravated by standing and walking. The requested SI joint RFA is 
considered experimental/investigational in nature, as studies have shown it does not improve outcomes 
compared to standard treatments for SI joint pain. The services are not reasonable or medically necessary at 
this time. 
 
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 sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64491 and 64492 billed for date of service 
January 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim should be paid 100 percent. The Plan 
denied your request. The Plan says the codes are packaged into payment for code 64490. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 64491 and 64492 are packaged items when provided in an ambulatory surgical center. 
No separate payment may be made. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 64491 and 64492 billed for date of service January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT) (G6002, 77014, 77520, 
77522, 77523, 77525). 
 
You asked the Plan to pre-approve PBT. You say that PBT is medically necessary. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found most (or all) radiation oncologists believe that proton therapy has a role in the treatment of 
some cancer patients. This enrollee with a scan showing positive nodes will likely undergo pelvic radiation 
though the records do not specify the treatment plan with respect to dose, fractionation or target volume. For 
this case, the enrollee has stage IV disease with apparent regional lymph node involvement. The enrollee is 
being offered pelvic/prostate radiotherapy. On January 6, 2023, an MRI showed no evidence of disease, so it is 
unclear why a 41-fraction plan was provided. Whether proton therapy for prostate cancer affords any advantage 
over IMRT is very controversial.  Most reports, including a systemic review conclude that enrollees treated 
with proton therapy fare comparably and/or better to enrollees treated with photon radiation (i.e., IMRT). There 
is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms 
of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive 
therapy. Several ongoing cooperative groups studies include acceptable dosimetric constraints for enrollees 
undergoing pelvic radiation for high-risk prostate cancer. Case reviews for proton therapy for prostate cancer 
are challenging since proton therapy will invariably reduce OAR exposure- but not always in a clinically 
meaningful way. The bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an 
accepted treatment approach.  While our reviewer does not think that proton therapy is an experimental 
therapy, any potential benefit or detriment of proton therapy over standard IMRT for routine cases is 
investigational. The decision is unfavorable in that the LCD criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam therapy (PBT) (G6002, 77014, 77520, 77522, 77523, 77525).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on August 16, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this device was used outside the home and is non-
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 pay for a pneumatic compression device (E0673, E0675) provided on August 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee stated both of her knees are 
bone on bone. The enrollee is seeking to avoid knee replacement surgery. The enrollee states that the physical 
therapy is helping. The Plan denied your request. The Plan says this is not medically necessary and the 
enrollees functions are within functional limits and should be discharged to a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee does not require continued unique input from a skilled 
therapist. The enrollee is able to continue with a home exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires this device, to help 
manage her complicated respiratory needs at home. The enrollee has an extensive pulmonary history including 
COPD, bronchiectasis, emphysema, and chronic hypoxic respiratory failure. She experiences extreme shortness 
of breath with even minor exertion. The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in AC mode with very low tidal volumes that could be delivered by BiPAP is not 
covered. 
 
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 severe COPD and 
bronchiectasis. The Life2000 device is not a true ventilator, because it is not capable of providing full 
ventilatory support. Its primary intended use is during activity, and not to treat chronic CO2 retention during 
sleep. In any case, this enrollee's ABG does not show CO2 retention. There is inadequate evidence of the safety 
and effectiveness of this device in the treatment of COPD. 
 
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 (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 enrollee is functioning at a home care level. The enrollee's progress also makes clear intensive rehabilitation therapies are not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fender light assembly (K0108). 
 
You asked the Plan to pre-approve fender light assembly. You say that this item needs to be repaired. The Plan 
denied your request. The Plan says this item does not serve a medical purpose, and therefore is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve fender light assembly (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have diabetes. The Plan denied your 
request. The Plan says based on the information submitted, there is no documentation that you meet all three 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).