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

 
We decided that the Plan does not have to pre-approve a transcatheter tricuspid valve implantation 
(TTVI)/replacement with prosthetic valve (0606T). 
 
You asked the Plan to pre-approve transcatheter heart valve procedure. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the requested transcatheter heart valve device and/or 
procedure is considered experimental, investigational or unproven. 
 
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 transcatheter heart valve procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that based on current clinical guidelines, there are insufficient randomized 
clinical data at this time to support the use of transcatheter tricuspid valve repair (TTVR) in this setting. As 
such, it would not be considered medically appropriate and necessary in this enrollee's management. At the 
current time, TTVR is not considered medically necessary for this 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 transcatheter heart valve procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a transcatheter tricuspid valve implantation (TTVI)/replacement 
with prosthetic valve (0606T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798 and 87801 billed for date of service 
February 20, 2023. 
 You asked the Plan to pay for procedure codes 87798 and 87801. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87798 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. 
 
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 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. We find that CPT code 87801 is not supported in the medical record. Specifically, the 
records show that multiple infectious agent detection was performed but the number of units billed is not 
supported. 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 codes 87798 and 87801 billed for date 
of service February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99356 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for procedure code 99356. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99356 is: Prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to 
code for inpatient or observation Evaluation and Management service). 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the medical record indicates 
that services were rendered over a span of 55 minutes. The Plan has paid for 55 minutes of care under code 99222. The medical record does not support additional, prolonged services. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99356 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99356 billed for date of service December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a Freestyle Libre 2. 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that the medical records support the medical 
necessity for the CGM. The Plan denied your request. The Plan says the enrollee is not on insulin and does not 
have documentation of problematic hypoglycemia.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 2. Our reviewer says 
that the Freestyle Libre 2 is not medically necessary. Our physician reviewer found coverage criteria for the 
prescribed CGM require insulin use or low blood glucose sugar levels. The enrollee is not using any 
medication for diabetes mellitus (insulin or orals). Although a CGM might help, coverage criteria for the CGM 
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 the Freestyle Libre 2  have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  a Freestyle Libre 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and segmental pneumatic appliances. You 
say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee has not 
completed a four-week trial of regular, daily, multiple-hour home usage of the E0650 or E0651.  
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device.  
 
You asked the Plan to pre-approve a Barostim Neo device. You say that this is covered by Medicare and should 
be covered by the Plan. The Plan denied your request. The Plan says the clinical value and effectiveness of this 
device in the setting of congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 device. Our reviewer 
says that the requested Barostim Neo device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this patients 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) provided January 3, 2023 
 
You asked the Plan to pay for the orthosis. You say that the prescribing physician recommends an extended 
lifetime use of equipment as the enrollee is diagnosed with chronic pain and compromised mobility without the 
option for surgical correction. The Plan denied your request. The Plan says the diagnosis code does not 
substantiate the service. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in the record provided, there is a single clinic note from September 2022 by the treating 
physical therapist leading an experienced clinician to suspect that the enrollee might have a qualifying 
diagnosis of knee arthritis (e.g., M17: Osteoarthritis of knee series, because they refer to the need for the brace 
to unload a knee compartment). However, there is no physical exam to describe knee instability as the LCD 
requires and also no ICD-10 codes attributed to the enrollee that fall within any of the covered diagnostic 
groups per the LCD.  The M25: Other joint disorder, not elsewhere classified and M24: Other specific joint 
derangements series ICD-10 codes listed on the prescription simply are not on Medicares lists of conditions 
for which these knee braces are covered. In reality, this enrollees condition probably does make the brace 
provided generally reasonable and necessary, but the deficiencies in documentation mean that Medicare policy 
cannot compel the Plan to cover it. Meanwhile, there is also no evidence in the EOC that the Plans contract 
with the Beneficiary requires such coverage either. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1851) provided January 3, 2023
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services rendered from March 1, 2023, to March 
31, 2023. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say to code all dialysis claims using HCPCS code 90999 along 
with the appropriate G modifier listed in section B.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed correctly per 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 the dialysis services rendered from March 1, 
2023, to March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204, 99214) with a 
hematologist/oncologist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you have metastatic stage 3 lung and bone 
cancer that is spreading. Your physician instructed you to see a hematologist as soon as possible to begin 
cancer treatment. The Plan denied your request. The Plan says you must use network providers to get your 
medical care and services. 
 
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 (99204, 99214) with a hematologist/oncologist 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 codes 93320 and 93325 billed for date of service 
December 15, 2022.  
 
You asked the Plan to pay for procedure codes 93320 and 93325. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 93320 and 93325 is bundled into 
payment for other codes. 
 
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 codes 
93320 and 93325 are column II codes to column I code 99306 with a modifier indicator of 0. The column II 
codes are 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 codes 93320 and 93325 billed for date 
of service December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on May 12, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that this is a dual plan, and this claim still needs to 
be processed by the Medicaid portion of the Plan. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 8, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for ambulance services have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on May 12, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88381, 88341, 88342, 88377, and 88360 
billed for date of service December 17, 2021. 
 You asked the Plan to pay for procedure codes 88381, 88341, 88342, 88377, and 88360. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88381, 88341, 88342, 
88377, and 88360. This means there is both a professional and technical component for the CPT codes. In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT codes 
88381, 88341, 88342, 88377, and 88360. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88381, 88341, 88342, 88377, and 88360 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88381, 88341, 88342, 88377, and 88360 billed for date 
of service December 17, 2021.
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 requires a ventilator for the 
treatment of severe COPD and chronic respiratory failure. 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 enrollee has COPD and chronic 
respiratory failure will substantial documentation to support home BIPAP with average volume assured 
pressure support (AVAPS). There is no documented record of failure or rising carbon dioxide (CO2) levels 
with BIPAP use. Hence, the enrollee does not meet criteria for home ventilation at this junction given provided 
documentation. BIPAP with AVAPS is reasonable option 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast lift (19316). 
 
You asked the Plan to pre-approve the surgical service. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is considered cosmetic and therefore is not 
covered.  
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical service. Our reviewer says 
that the requested surgical service is not medically necessary. Our reviewer found the record indicates that the 
enrollee has a distant history of breast cancer treated with lumpectomy and radiation. The enrollee now has 
ptosis and wishes to achieve breast symmetry. The record provided supports that the requested procedure is 
cosmetic to reshape the breasts to improve appearance. Therefore, the reviewer found that the requested 
surgical procedure is not medically reasonable or 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 the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a breast lift (19316).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. 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 enrollee has COPD and obesity 
hypoventilation syndrome. The enrollee was recently hospitalized with pneumonia and arterial blood gas 
(ABG) was consistent with mild acute on chronic hypercarbic respiratory failure. There are no pulmonary 
function tests to assess the severity of the COPD. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. This enrollee may benefit from BiPAP with average volume assured pressure support 
(AVAPS) during sleep 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 Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90832 billed for date of service February 16, 
2023. 
 
You asked the Plan to pay for procedure code 90832. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 CPT code 90832 is not supported. Specifically, the code at issue has been reported with POS code 
13, indicating an assisted living facility. However, the case record indicates services were rendered in an 
inpatient setting. Based on this information, we decided that Medicare rules for coverage of procedure code 
90832 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 90832 
billed for date of service February 16, 2023.