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 BiPAP therapy will be insufficient to meet 
the enrollee's needs. The enrollee requires one to two liters of oxygen continuously around the clock. The 
enrollee urgently requires a ventilator, or she is at high risk for death. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of a ventilator. 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was treated with BiPAP, and ventilator-associated pneumonia (VAPS) settings have been 
ordered. The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
average volume assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 99153. You say that the records illustrate the services were 
needed. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
 We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for procedure code 99153 billed for date of service May 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF services provided from 
November 1, 2022, to November 12, 2022. 
 You asked the Plan to pay for the SNF services. You say that you have submitted a corrected claim and 
medical records. The Plan denied your request. The Plan says you did not submit the original claim with a valid 
HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that HIPPS codes are alpha-numeric codes of five 
digits.  In this case, you submitted the claim with only a 4-digit code of OKPE.  You need to append the correct 
digit in the 5th place in order for the HIPPS code to be valid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF services provided from November 1, 2022, to November 12, 2022. 
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional image guidance radiation therapy (IMRT) 
treatment (G6001). 
 
You asked the Plan to pre-approve additional IMRT. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says there is not enough evidence that this type of 
radiation therapy guidance is needed or effective for the enrollee's skin cancer. 
 
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 additional IMRT. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the most recent National Comprehensive Cancer Network (NCCN) (v1.2023) 
guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient long-term 
efficacy and safety data to support routine use of electronic surface brachytherapy. Earlier versions (1.2016 
and before) did not specifically address electronic brachytherapy (EBT) or superficial radiation (SRT), and 
only mentioned electron and orthovoltage beams as means to deliver radiation.  Generally, electron therapy or 
orthovoltage therapy are considered standard means to deliver radiation. Electronic brachytherapy is currently 
subject only to medical device review by the Food and Drug Administration (FDA), which considers safety and 
effectiveness of the device based on a standard that does not assess efficacy, outcomes, or potential clinical 
applications. For this case, there are no compelling reasons offered for why SRT would be needed over more 
standard approaches of radiation delivery. The decision in this case is unfavorable due to lack of demonstration 
of need for SRT versus traditional external beam radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional IMRT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional image guidance radiation therapy (IMRT) treatment (G6001).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodontal scaling and root planing (D4341). 
 
You asked the Plan to pay for periodontal scaling and root planing (D4341). You say that the medical criteria 
for this dental work have been met. The Plan denied your request. The Plan says that documentation submitted 
does not demonstrate evidence of significant bone loss. 
 
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. The Plan covers periodontal 
scaling and root planing (D4341) when the services are medically necessary and reasonable. 
 
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 periodontal scaling and root planing 
(D4341). Our reviewer says that D4341 is medically necessary. Our physician reviewer found the 
documentation provided meets the criteria for coverage for D4341 in the upper right quadrant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing (D4341) have been met. Therefore, we 
decided that the Plan has to pay for periodontal scaling and root planing (D4341).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Gemzar (J9201) and Platinol (J9060). 
 
You asked the Plan to pre-approve Keytruda, Gemzar and Platinol. You say that you are requesting an 
expedited appeal including supporting note, case study and clinicals. The Plan denied your request. The Plan 
says the requested use of this drug combination is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Keytruda, Gemzar and Platinol. Our 
reviewer says that the requested drug combination is not supported. Our physician reviewer found the 
requested regimen is similar to cisplatin, Gemzar and durvalumab for which there has been progression of 
disease. Therefore, the service is not reasonable or 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 Keytruda, Gemzar and Platinol have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Keytruda (J9271), Gemzar (J9201) and Platinol (J9060).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the TissueCypher Barret's Esophagus test (0108U) provided on January 
30, 2023. 
 
You asked the Plan to pay for the TissueCypher Barret's Esophagus test. You say that this test is a covered 
Medicare benefit. The Plan denied your request. The Plan says that this testing is not medically necessary. 
 
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 pay for the TissueCypher Barret's Esophagus test. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that Medicare has approved this as an advanced test. This testing is 
medically reasonable and 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 TissueCypher Barret's Esophagus test have been met. Therefore, we decided 
that the Plan has to pay for the TissueCypher Barret's Esophagus test (0108U) provided on January 30, 2023.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 28, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was previously seen by the same 
physician for ER services related to the same complaints on the same date of service. These services must be billed as a single visit. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) 
services rendered on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E0995, E1002, E1028, E2361, E2603, 
E2620, K0040, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option and 
additional items and accessories. You say that the enrollee is wheelchair bound and is dependent for 
ambulation. The Plan denied your request. The Plan says the enrollee does not have medical need for single 
power options included with group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. 
 
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 group 3 standard power wheelchair 
with single power option and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found in this case, the enrollee has a neurologic disorder 
with functional deficits. The documentation does not indicate that the enrollee has any pressure injuries or 
requires intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or 
recline. Our reviewer found that although the enrollee's condition may meet criteria for a PWC, the criteria for 
this specifically requested PWC with multiple power options including power tilt and recline 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 a group 3 standard power wheelchair with single power option and additional 
items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with single power option (K0856) and additional items and accessories 
(codes E0955, E0995, E1002, E1028, E2361, E2603, E2620, K0040, and K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2023. 
 
You asked the Plan to pay for the office visit. You say that no authorization is required for mental health 
services. The Plan denied your request. The Plan says services from non-participating providers are not covered 
under open access unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on October 7, 2022, and billed with codes 87801, 87798, 87651, 87641, 87640 and 87500. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
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. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel 
provided on October 7, 2022, and billed with codes 87801, 87798, 87651, 87641, 87640 and 87500.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics billed for date of service April 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that you provide products for the enrollee's concern. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The file shows that diabetic shoe inserts were billed with codes A5500-LT-KX, A5500-RT-KX, A5512-LT-KX 
and A5512-RT-KX. The record does not contain a valid physician order, proof of delivery, or relevant medical 
records which support medical necessity for the supplies provided in this case. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the foot orthotics billed for date of service April 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for procedure codes 43276-59 and 43265 billed for date 
of service April 5, 2023. 
 
You asked the Plan to further pay for the billed services. You say that the procedure was the best treatment for 
the enrollee. The Plan denied your request. The Plan says the payment for the codes is included in the payment 
for code 43276. 
 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 looked at the file and the rules. The Plan paid the allowed amount for the highest valued endoscopy 
(43276); plus, the difference between the next highest value (43276-59) and the base code (43260); plus, the 
difference between the next highest value (43265) and the base code. Instead of putting the payments on each 
claim line, the Plan combined the total amounts and listed it under claim line 1. Therefore, we decided that the 
Plan does not have to further pay for procedure codes 43276-59 and 43265 billed for date of service April 5, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the documentation provided, transportation via ambulance is not medically necessary. The enrollee is 
not bedbound. The enrollee does not require the expertise of trained personnel or the equipment available only 
on an ambulance in order to effectuate a safe transport. Transportation can be provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
August 31, 2022, to September 21, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not a covered item. 
 
The Plan follows Medicare rules. The rules state 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 the pneumatic compression device (E0675) provided from August 31, 2022, to September 21, 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 admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the records do not show the enrollee will be expected to 
improve with LTACH treatment and show poor prognosis with limited outlook. Care is being provided in the 
current hospital. 
 
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.