Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on July 27, 
2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the treatment you received in the 
emergency department is not related to hospice. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
You were under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99285) provided on July 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on October 10, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) 
provided on October 10, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior tibial nerve stimulation device. 
 
You asked the Plan to pre-approve a posterior tibial nerve stimulation device. You say that the enrollee has 
been getting this treatment for over a year and needs to continue to receive it. The Plan denied your request. 
The Plan says a posterior tibial nerve stimulation device 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 a posterior tibial nerve stimulation 
device. Our reviewer says that a posterior tibial nerve stimulation device is not medically necessary. Our 
physician reviewer found that the records do not document failure of or intolerance to standard anticholinergic 
drug therapy or significant improvement in bladder symptoms with the device and the need for the additional 
posterior tibial nerve stimulation treatments, as would be the standard of care for this device. Also, there is no 
documentation that the continuation of treatment with a posterior tibial nerve stimulation device meets all 
Medicare criteria for medically reasonable and necessary and safe and effective 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 a posterior tibial nerve stimulation device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a posterior tibial nerve stimulation device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services with an OON provider. You say that the services are 
medically necessary. The Plan denied your request. The Plan says there are in network providers who can 
provide the 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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on June 28, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
supplies and accessories provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital hearing aids (V5257 and V5261 x2) purchased on 
July 5, 2023, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the digital hearing aids. You say that under the coverage section it says that 
hearing aids are covered, and the copay is $199 or $499 depending on what kind of hearing aid was purchased. 
You also say that this claim shows denied with no benefits being paid. The Plan denied your request. The Plan 
says this claim was processed correctly. The Plan also says they confirmed with the Plan's approved hearing aid 
vendor that you have never contacted them about your hearing aid benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor.  
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received these hearing aids from a non-
Plan approved hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of 
the digital hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the 
digital hearing aids (V5257 and V5261 x2) purchased on July 5, 2023, from an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy, per session (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are medically necessary. Our physician reviewer found documentation 
supports that the enrollee meets criteria for services requested, including known diabetes, foot ulcer with 
Wagner 3 class, and has failed conventional therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician attendance and 
supervision of hyperbaric oxygen therapy, per session (99183).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar percutaneous vertebral augmentation (22514, 
22515).  

You asked the Plan to pre-approve lumbar percutaneous vertebral augmentation. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 lumbar percutaneous vertebral 
augmentation. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
detailed documentation is not evident regarding an acute or subacute fracture at L3 or L4 levels. Additionally, 
there is no documentation of a progression of the body height loss, greater than 25% vertebral body height loss, 
kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging 
(MRI) corroboration of other plausible causes of pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lumbar percutaneous vertebral augmentation (22514, 
22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement calf pads (E0995). 
 
You asked the Plan to pre-approve replacement calf pads. You say that the item is necessary. The Plan denied 
your request. The Plan says replacement calf pads are listed under Column II and the power wheelchair 
approved is under Column I. The replacement calf pads are included in the group 3 power wheelchair and 
cannot be unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a Column II code is included in the allowance for 
the corresponding Column I code when provided at the same time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement calf pads have not been met. Therefore, we decided that the Plan does not have to pre-
approve replacement calf pads (E0995).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the drug. You say that these drugs are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the drug is not medically necessary. 
 
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 the drug. Our physician reviewer found 
the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a simpler device has been deemed insufficient. 
The Plan denied your request. The Plan says ventilators used to provide BiPAP therapy is not covered.  
 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 ventilator. Our physician reviewer 
found that the enrollee has chronic obstructive pulmonary disease with chronic respiratory failure. The enrollee 
was admitted to the acute hospital and treated with BIPAP therapy. The enrollee did not have failure of BIPAP 
nor required escalation of therapy.  There is no indication for a home ventilator 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 provided 
on September 28, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 provided on September 28, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient surgery for anterior lumbar interbody fusion. 
 
You asked the Plan to pre-approve inpatient surgery for anterior lumbar interbody fusion. You say that the 
enrollee has lower back pain that is affecting their quality of life. The Plan denied your request. The Plan says 
criteria for spinal surgery has not been met. 
 
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 inpatient surgery for anterior lumbar 
interbody fusion. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found a standard of care for fusion is to have smoker stop 
smoking for 6 weeks to 3 months prior to surgery and to have smoking cessation confirmed with cotinine test. 
Fusion is less successful in active smokers and not recommended with active smokers. The enrollee has not met these criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient surgery for anterior lumbar interbody fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient surgery for anterior lumbar 
interbody fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85347-26 provided on June 28, 2023. 
 
You asked the Plan to pay for procedure code 85347-26. 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. The 
rules say that the TC and 26 modifiers should not be used with codes with a PC/TC indicator of 9, as the 
concept of a professional and technical component does not apply to these codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85347 have not been met. Specifically, code 85347 has a PC/TC indicator of 9 
but was billed with modifier 26. It is not appropriate to use modifier 26 with code 85347. Therefore, we 
decided that the Plan does not have to pay for procedure code 85347-26 provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that BiPAP devices are pressure limited. The Plan 
denied your request. The Plan says the severity of illness does not justify the need for 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 ventilator. Our physician reviewer 
found that the enrollee has obesity hypoventilation syndrome with thoracic restrictive disease and chronic 
respiratory failure. The enrollee was treated and improved with BIPAP therapy and despite the severity of 
disease, did not require escalation of therapy. Therefore, there is no indication for a home ventilator 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to go to the SNF for recovery 
after a fall. You say the enrollee needs speech therapy and physical therapy. The Plan denied your request. The 
Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a long-term care setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you have reached the benefit limit for the 
calendar 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 60 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.