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

 
We decided that the Plan does not have to pre-approve a Life2000 ventilator. 
 
You asked the Plan to pre-approve a Life2000 ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says you do not have a diagnosis that meets criteria, and the requested ventilator 
is not a true 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 Life2000 ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found the records do not 
document that you have severe chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or 
generalized neuromuscular disease, and there is no evidence of chronic carbon dioxide retention. The Life2000 
system is also not a true ventilator, because it is not capable of providing full ventilatory support.  There is 
inadequate evidence of the safety and efficacy of this device in the treatment of COPD or interstitial lung 
disease. 
 
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 Life2000 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Life2000 ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19318 billed for date of service September 
27, 2021. 
 You asked the Plan to pay for procedure code 19318. 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 19318 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 19318 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 19318 billed for date of service September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are considered chiropractic maintenance 
care which is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
you do not meet criteria for coverage of the requested services. Our physician reviewer found that in this case, 
the record indicates that you have a subluxation of the spine. The records provided do not indicate that you 
have an acute condition for which chiropractic care is required. The records of these visits do not support 
progressive improvement of symptoms but rather maintenance therapy. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested services. The 
elements of the coverage criteria are not satisfied. The requested services are not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments (98940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic respiratory failure 
with hypercapnia and the home ventilator is needed to prevent hypoxia for chronic respiratory failure. 
 The Plan denied your request. The Plan says Medicare guidelines say home NIVs are not reasonable and 
necessary when the sole purpose of the home NIV is to function as a respiratory assist device (RAD). 
 
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 
COPD, but there are no pulmonary function tests to confirm airways obstruction and assess severity. A recent 
ABG, apparently done while stable as an outpatient, showed mild compensated CO2 retention. The enrollee 
currently has BiPAP at home, with good compliance. This enrollee may benefit from BiPAP with the AVAPS 
mode.  This has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve occupational therapy services. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is 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 
occupational therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for June 20, 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 procedure code 99223 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We asked our coder 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 these services. Our reviewer says that procedure code 99223 is not supported by the medical records. Our reviewer found the enrollee was treated in the hospital on June 20, 
2022. The provided documentation from that date showed a detailed history describing the enrollee's symptoms 
of a foreign body sensation in throat with difficulty swallowing and vomiting, but had no aspiration, no 
difficulty breathing or difficulty talking. The physical examination was detailed and unremarkable overall. No 
foreign body was seen on imaging. The enrollee was otherwise stable and there is insufficient evidence of 
medical decision-making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for June 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elevating leg rests (K0195) provided on May 2, 2022. 
 
You asked the Plan to pay for elevating leg rests. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that elevating leg rests can be covered if 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 pay for elevating leg rests. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the clinical documentation provided does 
not support the need for leg rests for the enrollees wheelchair. The enrollee is noted to have limited mobility 
and bilateral club feet. There is limited clinical history regarding the enrollees level of mobility and physical 
examination findings, specifically with regards to lower extremity strength and range of motion. There is no 
indication of contracture at the knee joints or significant lower extremity edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating leg rests have not been met. Therefore, we decided that the Plan does 
not have to pay for elevating leg rests (K0195) provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of carotid sinus baroreflex activation 
device and generator (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that services are medically necessary. The 
Plan denied your request. The Plan says a review of the current medical literature does not consider this service 
to be standard medical treatment for the enrollee's condition. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator 
implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse 
generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the 
carotid arteries. In August 2019, the FDA approved the system for use in enrollees with refractory heart failure 
who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have 
an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical 
study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in enrollee management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's 
clinical management. 
 
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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantation of carotid sinus baroreflex activation device and generator 
(0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) genicular nerve blocks (left knee). 
 
You asked the Plan to pre-approve three (3) genicular nerve blocks (left knee). You say that three (3) genicular 
nerve blocks (left knee) are medically necessary. The Plan denied your request. The Plan says the requested 
genicular nerve blocks are experimental and investigational. 
 
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 three (3) genicular nerve blocks (left 
knee). Our reviewer says that the requested genicular nerve blocks (left knee) are not considered medically 
reasonable and necessary. Our physician reviewer found that genicular nerve blocks and radiofrequency 
ablation (RFA) are considered experimental procedures. They are the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically 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 three (3) genicular nerve blocks (left knee) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve three (3) genicular nerve blocks (left knee).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need to get to 
medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 4, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together. 
 
We looked at the file and Medicare rules. In this case, the billed diagnosis code K63.5 has an Excludes1 note. 
This note indicates that diagnosis codes K63.5 and D12.6 cannot be billed together on the same claim. As such, 
the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
provided on January 4, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve venous catheter placement with ultrasound guidance, venography, 
and sedation. 
 
You asked the Plan to pre-approve venous catheterization. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this 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 pre-approve venous catheterization. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had prior varicose vein procedures including ablation but continues 
to have lymphedema and varicosities as well as soft tissue ulceration. The request for intravenous ultrasound 
and conscious sedation as well as venography is reasonable based upon the persistent symptoms including 
ulceration and lymphedema provide adequate indications for the requested procedures including the 
intravascular ultrasound, sedation and venography to search for Iliac vein compression, and May-Turner 
syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venous catheterization have been met. Therefore, we decided that the Plan has 
to pre-approve venous catheter placement with ultrasound guidance, venography, and sedation.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure c ode 96401 billed for date of service November 
1, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
 The file shows that a Prolia injection was provided to treat osteoporosis. We find that CPT code 96401 is not 
supported in the medical record. Specifically, there is a more appropriate code available for the injection 
services at issue. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure c ode 96401 billed 
for date of service November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient evaluation and management (EM) services 
provided on September 2, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says documentation does not support the billed 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. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 EM services as billed. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the history and physical examination from 
that date was brief and focused and the patient was described as hemodynamically stable with recent surgery 
with no complications, tolerating and responding to treatment for urinary tract infection/pneumonia, showing 
no evidence of medical decision-making of high complexity to meet criteria for code, 99223. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient evaluation and management (EM) services provided on September 2, 
2022, billed with code 99223.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Infed and Venofer before it will approve 
Injectafer. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Injectafer. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not show that 
these drugs would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Injectafer.