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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and 
segmental pneumatic appliance for the trunk. 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. 
 
The Plan follows Medicare rules. Medicare rules say that Pneumatic Compression Devices are covered when 
specific criteria 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 pneumatic compressor, full leg 
segmental pneumatic appliance, and segmental pneumatic appliance for the trunk. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the pneumatic compression device at issue in this case meets all Medicare 
criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not document 
lymphedema of the chest, trunk or abdomen or four weeks of regular, daily, multiple-hour home usage of a 
basic pump after careful, in-person fitting, training and supervision by a technician who is skilled in and who 
regularly and successfully uses the appliance provided. 
 
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 pneumatic compressor, full leg segmental pneumatic appliance, and segmental 
pneumatic appliance for the trunk have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you are totally disabled and have a 
condition of neuropathy, back problems from surgery that won't allow you to stand up for long periods of time 
at all. The Plan denied your request. The Plan says the information received does not meet criteria because you 
do not have a neuromuscular diagnosis or severe arthritis in the hip or knee, and the seat-lift mechanism is not 
part of a physician-prescribed treatment. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you have a degenerative back 
condition with failed surgery. You do not have a neuromuscular disease or documented severe hip djd. The 
LCD criteria has not been 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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service November 
12, 2022.  
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99222 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99222 is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99222 billed for date of service November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refilling and maintenance of implantable pump or 
reservoir for drug delivery (95990) provided on December 7, 2022. 
 
You asked the Plan to pay for the physician service. You say that this service was denied in error. You say that 
this drug is covered for chronic pain. You also say that this was medically necessary. The Plan denied your 
request. The Plan says there was no information provided to support the medical necessity of the service in this 
case. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the physician service have been met. 
There was no documentation provided to support the medical necessity of the service at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the refilling and maintenance of implantable pump 
or reservoir for drug delivery (95990) provided on December 7, 2022.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 health Plans denial should be upheld. The enrollee did not require the 
intensity of services provided at an IRF. Specifically, the enrollee was not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37221 billed for date of service December 2, 
2022. 
 You asked the Plan to pay for procedure code 37221. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 37221 is bundled into payment for code 34717. 
 
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, we have confirmed that code 37221 
is a column II code to column I code 34717. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 37221 billed for date of service December 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial. The enrollee is in 
the midst of treatment and has a strong family history of cancer. The Plan denied your request. The Plan says 
the enrollee must receive your care from a network provider. The enrollee's radiation therapy was finished and 
there were no complications noted. There are providers available in-network. 
 
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 
an office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for procedure code 99358. You say that the enrollee was seen by different specialties 
on this date. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete upper denture (D5110) and a complete lower denture 
(D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures. The Plan denied 
your request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The proper Evidence of Coverage (EOC) was not received; therefore, we could 
not determine if the benefit level for the requested dentures was exhausted. Therefore, we decided that the Plan 
has to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on December 20, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. 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 laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc procedure. 
 
You asked the Plan to pre-approve the Via Disc procedure. You say that the requested Via Disc procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Via Disc procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Via Disc procedure. Our reviewer 
says that the requested Via Disc procedure is not medically necessary. Our physician reviewer found the Via 
Disc procedure is experimental. More research is needed 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 the Via Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Via Disc procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 17, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the panel was 
not billed with one code. 
 
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 the urinary tract infection panel testing was not billed with a single code as required. 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 the lab testing billed for date of service January 17, 2023.
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 requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
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. 
 
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 enrollee does not meet criteria for a home ventilator. Our physician reviewer found provided records in 
this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary 
disease although provided records do not document any pulmonary functional testing or arterial blood gas 
results to support the diagnosis. Provided records in this case do not provide adequate detailed information to 
meet Medicare criteria for coverage of a ventilator as opposed to a bilevel positive airway pressure (BiPAP) 
device with average volume-assured pressure support (AVAPS) and a back-up rate. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715), and administration (90471) provided on May 17, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you would like this to be covered. You also 
say that you need help. The Plan denied your request. The Plan says this vaccine is not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715), and administration (90471) provided on May 17, 2022.  
 Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy service provided on July 27, 
2022. 
 
You asked the Plan to pay for the medical nutrition therapy service. You say that due to the enrollee's 
condition, medical history and clinical assessment, this is medically appropriate for the enrollee. The Plan 
denied your request. The Plan says this service is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy service provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment for teeth 7, 9 ,10 (D6057), 
abutment supported retainer for teeth 7, 9, 10 (D6068) and pontic tooth 8 (D6245). 
 
You asked the Plan to pre-approve custom fabricated abutment, abutment supported retainer and a pontic. You 
say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says the teeth have 
poor or questionable prognosis so are not covered. 
 
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 custom 
fabricated abutment, abutment supported retainer and a pontic 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 pre-approve custom fabricated abutment, abutment 
supported retainer and a pontic. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the documentation provided was incomplete. There were no radiographs of the total arches. 
There appear to be implant bodies in place in areas #7. 9 and 10. According to the EOB, two implants/year are 
covered. 
 
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 custom fabricated abutment, abutment supported retainer and a pontic have not 
been met. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment for 
teeth 7, 9 ,10 (D6057), abutment supported retainer for teeth 7, 9, 10 (D6068) and pontic tooth 8 (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Parietal Cell Sparing Gastrectomy Gastro-jejunostomy. 
 
You asked the Plan to pre-approve Parietal Cell Sparing Gastrectomy Gastro-jejunostomy. You say that the 
requested Parietal Cell Sparing Gastrectomy Gastro-jejunostomy is medically necessary. The Plan denied your 
request. The Plan says the requested Parietal Cell Sparing Gastrectomy Gastro-jejunostomy is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Parietal Cell Sparing Gastrectomy 
Gastro-jejunostomy. Our reviewer says that the requested Parietal Cell Sparing Gastrectomy Gastro-
jejunostomy is not medically necessary. Our physician reviewer found provided medical records and review of 
the current peer-reviewed medical literature do not document that parietal cell sparing gastrectomy gastro-jejunostomy has been shown in controlled studies in a CMS-approved journal to result in long term health 
benefits in patients with severe gastroesophageal reflux disease with a hiatal hernia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Parietal Cell Sparing Gastrectomy Gastro-jejunostomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Parietal Cell Sparing Gastrectomy Gastro-
jejunostomy.