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

 
We decided that the Plan does not have to pre-approve a portable ventilator (identified with with code E0466)  
 
You asked the Plan to pre-approve a portable ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a portable ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee has COPD. The enrollee had recent pneumonia. The enrollee does have 
chronic respiratory failure and would likely benefit from optimization of therapy and possibly BIPAP, but a 
home ventilator is not indicated per documentation provided. The enrollee has not trialed or failed bilevel 
positive airway pressure (BIPAP). Therefore, the enrollee does not meet criteria for the requested device.. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (identified with with code E0466)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of procedure code 62323 billed for date of service 
July 14, 2023.  
You asked the Plan to pay for 2 units of procedure code 62323. You say that all units of code 62323 are 
supported in the documentation and were medically necessary. The Plan denied your request. The Plan says the 
billed number of units are not supported by the records as both provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 62323 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 for 62323. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found it is not medically reasonable 
and necessary to perform caudal epidural steroid injections or interlaminar epidural steroid injections 
bilaterally, therefore 62323 is not a bilateral procedure. Code 62323 may only be reported for 1 level per 
session. In this case, the provider submitted 2 different claims for 62323 for the same billed date of service, 
totaling 2 units. The provider received the appropriate payment for 1 unit of code 62323 billed on July 14, 
2023. The records also do not support that the additional units were reasonable or necessary in this case.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 62323 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 62323 billed for date of service July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a consultation. You say that this is regarding possible cancer. The Plan 
denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation to be provided by an out-of-network (OON) provider.
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 March 31, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
in an atrial fibrillation crisis and could have lost consciousness while driving so you called for emergency 
medical service assistance. You also say that if you drove to the emergency  room the claim would be covered 
so you are asking for reconsideration. 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 March 31, 2023. 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 March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT)  
 
You asked the Plan to pre-approve PBRT. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Several studies have shown that proton beam therapy for prostate cancer outside of a 
prospective clinical trial or registry is not routinely recommended. To date, there are no compelling data to 
suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-
guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. While National 
Comprehensive Cancer Network (NCCN) guideline consider proton therapy a reasonable alternative they do 
not describe it as being necessary in lieu of non-proton based treatment and are quite explicit in that there is no 
evidence of its superiority. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on July 4, 2023. 
 
You asked the Plan to pay for the eyeglasses. You say that this purchase should be covered under the Flex card 
benefits. The Plan denied your request. The Plan says you did not purchase the items with the Flex Card. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when The Flex Card is used for payment. Any other forms of payment 
used are not eligible for reimbursement. 
 
We looked at the file and the Plan's rules. The Flex Card was not used for this purchase. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses purchased on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum has already been exhausted. 
 
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, certain limitations apply. The record 
shows your $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 26, 2023.
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 this is medically necessary. The Plan 
denied your request. The Plan says the admission to an LTACH is not medically necessary. 
 
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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility.  
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee does not have support at home to care 
for them at the level needed. The Plan denied your request. The Plan says the enrollee does not need daily 
skilled nursing care or rehabilitation services. The enrollee can receive the care they need in another setting.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (scooter) 
(K0801). 
 
You asked the Plan to pre-approve a scooter. You say that the requested equipment is medically necessary 
because the enrollee does not have the ability to self-propel himself in a manual wheelchair. The Plan denied 
your request. The Plan says based on the composite of information, the enrollee does not meet the medical 
necessity for a powered wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 scooter. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the evidence does not support that the 
enrollee requires a powered wheelchair to complete MRADLs in the home.  
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 heavy duty power operated vehicle (scooter) (K0801).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays and two (2) periapical additional x-rays 
(D0220, D0230) and periodontal maintenance (D4910) provided on August 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the periapical x-rays and two (2) periapical additional x-rays was exhausted on date of 
service July 19, 2022. The benefits for the periodontal maintenance were exhausted on December 29, 2022, and April 6, 2023.  Therefore, we decided that the Plan does not have to pay for periapical x-rays and two (2) 
periapical additional x-rays (D0220, D0230) and periodontal maintenance (D4910) provided on August 7, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another several 
weeks of inpatient care for positive progression of their wounds. The Plan denied your request. The Plan says 
the enrollee can receive the same services at a lower level of care. 
 
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 the enrollee's needs can be met a lower level of care. The LTACH services are not 
reasonable or necessary in this case. 
 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services performed from February 10, 2022, 
through May 12, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the chiropractic services should be 
covered because they were submitted in a timely manner. The Plan denied your request. The Plan says the 
chiropractic services are denied because they were not submitted in a timely manner. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the chiropractic services was not filed until May 18, 2023. This means that 
more than one calendar year from the dates of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the chiropractic services performed from February 10, 2022, 
through May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a conforming bandage (A6446), collagen dressing (A6021), foam 
dressing, wound cover (A6212), and tape, non-waterproof (A4450). 
 You asked the Plan to pre-approve wound dressing supplies. You say that the provider is appealing the medical 
necessity denial for wound dressings because of other general symptoms and signs. The Plan denied your 
request. The Plan says that per LCD 33831, these wound supplies are only covered for full thickness wounds 
(stage 3 or 4 ulcers). Per the clinical supplied, your right ankle wound is at stage 2, therefore, the criteria are 
not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 wound dressing supplies. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a medical history of a right sided ankle wound. Other medical issues 
documented on a clinical progress note dated September 18, 2023, included cellulitis, arthritis, hypertension, 
and neuropathy. The enrollee was noted to have a chronic right ankle wound that is non-healing. She is 
currently used a matrix alginate dressing wrapped with gauze. The enrollee is noted to have heavy discharge. 
The physical examination showed a 6 centimeter (cm) right lateral ankle wound with yellow discharge that is 
documented as stage II. There is a left lateral ankle wound with scab and erythema that is 1.5 cm. The enrollee 
is noted to have chronic non-healing ankle wounds. They are noted to be stage II but have heavy drainage and 
are free from necrotic tissue or eschar. A wound does not necessarily have to be greater than stage II to use an 
alginate dressing. As long as there is healing by secondary intention and the wound environment is moist 
versus dry, it is indicated. Therefore, the requested wound care supplies are 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 wound dressing supplies have been met. Therefore, we decided that the Plan has 
to pre-approve a conforming bandage (A6446), collagen dressing (A6021), foam dressing, wound cover 
(A6212), and tape, non-waterproof (A4450).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PainTEQ LinQ procedure. 
 
You asked the Plan to pre-approve a PainTEQ LinQ procedure. You say that the enrollee needs this procedure 
for pain. The Plan denied your request. The Plan says current evidence-based medical literature does not 
support the use of the PainTEQ LinQ device for recurrent pain after sacroiliac fusion surgery. 
 
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 PainTEQ LinQ procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has sacroiliac joint pan following 
sacroiliac joint fusion. There is insufficient literature to support the safety and efficacy, as defined by Medicare 
rules, of the requested service.  
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 PainTEQ LinQ procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PainTEQ LinQ procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator provided on July 17, 2023. 
 
You asked the Plan to pay for an oxygen concentrator. You say that this service is supported in the records. 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 an oxygen concentrator 
provided on July 17, 2023.