Persius/hicric huggingface dataset:
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 device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for continued use of a non-invasive ventilator 
(NIV) is not medically necessary because the documentation does not support that this device meets but does 
not exceed the enrollee's need. 
 
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 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in targeted tidal volume, volume assured pressure support 
(TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD 
policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen. 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that you are having severe pain in your 
abdominal area and are unable to eat much. The Plan denied your request. The Plan says based on the 
information received, this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CT scan of the abdomen have been met. Medical records were not made available for review. Therefore, we decided that the Plan does not have to 
pre-approve a CT scan of the abdomen.
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 that the enrollee's clinical condition meets full IRF 
criteria and a lower level of care in a skilled nursing facility cannot provide the necessary care. The Plan denied 
your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 enrollees 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 16, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you never 
requested an ambulance and the 911 call was only to see if anyone could assist you with taking a COVID-19 
test. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount the review and interpretation of a new 
home, office, or lab international normalized ratio (INR) test result (93793) provided from October 17, 2022, to 
January 27, 2023. 
 
You asked the Plan to waive the cost share amount the diagnostic services. You say that you have been 
receiving these services since you had an unexplained pulmonary embolism in 1990 and 2014. You also say 
that you are able to do your own checks if they are covered. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.   
You have been asked to pay a $20 copayment for each of the four diagnostic services at issue in this case. 
These services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Additionally, the record 
shows that the copayments applied to these dates of service were less than the $20 copayment. Therefore, we 
decided that the Plan does not have to waive the cost share amount the review and interpretation of a new 
home, office, or lab international normalized ratio (INR) test result (93793) provided from October 17, 2022, to 
January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brow lift procedure and hospital stay. 
 
You asked the Plan to pay for the brow lift procedure and hospital stay. You say that the services should be 
covered. The Plan denied your request. The Plan says this service is not covered when obtain out of the 
Country. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the brow lift procedure and hospital stay have not been met. Therefore, we decided that the Plan 
does not have to pay for the brow lift procedure and hospital stay.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 5, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says to receive reimbursement for a Medicare member, the 
provider/facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glasses fitting, and repair (92370, 92341) provided on April 
13, 2021.  
You asked the Plan to pay for glasses fitting and repair. You say that at the appointment you stated you did not 
want anything done that was not covered. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
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. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of glasses fitting, and repair have not been met. Therefore, we decided that the Plan does not have to 
pay for glasses fitting, and repair (92370, 92341) provided on April 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs. 
 
You asked the Plan to pay for the medication. You say that the service should be covered. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the 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 pay for the self-administered drugs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on January 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that your dentist recommended the guard because 
you were grinding your teeth, but you did not know the full price. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the occlusal guard is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard (D9944) provided on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on February 
2, 2023. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you feel you require this unit because 
you get muscle spasms and cramps for which this unit will give you relief. You also say that the medications 
you are on do nothing for the spasms and muscle cramps, and you would rather use the unit than go on another 
medication. The Plan denied your request. The Plan says the diagnosis codes submitted with this request were 
for spinal enthesopathy and foot pain. The Plan also says that neither of these diagnosis codes presented with 
claim, nor the diagnosis presented in the clinical support the diagnosis of muscle disuse or atrophy.  
 
The Plan must follow Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is 
limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
 
 
 We looked at the file and Medicare rules. The record shows that you have been diagnosed with Other specified 
dorsopathies of the cervical region (M53.82), Spinal enthesopathy of the cervical region (M46.02), Spinal 
enthesopathy of the lumbar region (M46.06), and Pain in right ankle and joints of right foot (M25.571). None 
of your diagnoses fall under the required diagnoses for use of a NMES. Based on this information, we decided 
that Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided 
that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroscopy knee surgery (29881, 29877). 
 
You asked the Plan to pre-approve the arthroscopy knee surgery. You say that the services are medically 
necessary. 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 the arthroscopy knee surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident.  There is no indication that she has 
tried and failed physical therapy. Additionally, the provided diagnostic imaging studies demonstrate 
osteoarthritis in the knee. There are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 arthroscopy knee surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the arthroscopy knee surgery (29881, 29877).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit provided on January 09, 2023. 
 
You asked the Plan to pay for a home or residence visit. You say that it is the responsibility of the facility to 
obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
provided on January 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 5, 2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient surgery (00562, 36620, 36556, 76937), 
provided on November 29, 2022. 
 
You asked the Plan to pay for the inpatient surgery. You say that the services should be covered. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 25, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the inpatient surgery have not been met. 
Therefore, we decided that the Plan does not have to pay for the inpatient surgery (00562, 36620, 36556, 
76937), provided on November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility services billed with service code 
KGKE1 for date of service August 17, 2022, to August 19, 2022. 
 
You asked the Plan to pay for the skilled nursing facility services as billed. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the service is not payable 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. 
 
We find that service code KGKE1 is not supported in the medical record. Specifically, this claim line was 
billed without a charge amount. Without a claim line amount, this code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the skilled nursing facility services as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services 
billed with service code KGKE1 for date of service August 17, 2022, to August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87631-59 for date of service 
December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 billed with code 87631-
59 for date of service December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer Panel provided 
on November 26, 2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 
81321, 81351, 81209, 81209, 81314, 81334, 81335, 81272, and 81479. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this panel should be billed with a single 
panel code. Additionally, screening genetic testing is not a covered benefit.  
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. These tests were not billed with single panel codes as required. Based 
on this information, we decided that Medicare rules for coverage of the CGx Comprehensive Complete Cancer 
Panel  have not been met. Therefore, we decided that the Plan does not have to pay for the CGx 
Comprehensive Complete Cancer Panel provided on November 26, 2022, and billed with codes 81162, 81201, 
81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81209, 81314, 81334, 81335, 81272, and 
81479.