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

 
We decided that the Plan does not have to pre-approve a LinQ device. 
 
You asked the Plan to pre-approve a LinQ device. You say that this is medically necessary to help alleviate 
pain. The Plan denied your request. The Plan says this procedure is considered 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 a LinQ device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the LinQ device is experimental. Our physician reviewer also found that sacroiliac (SI) joint fusion for degenerative back pain, without documented SI joint instability, fracture, or lesion is also considered experimental. 
 
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 LinQ device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a LinQ device.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that you disagree with the denial and 
have submitted medical record documentation for review. The Plan denied your request. The Plan says that the 
request for continued use of a ventilator is not medically reasonable and necessary. 
 
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 9-month use of a ventilator. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has had 
chronic respiratory failure and utilizing a Trilogy ventilator since 2017. The enrollee should continue current 
therapy and change in therapy is substandard of care. The documentation supports the medical necessity and 
rationale for ventilator. The ventilator will not be used as BiPAP or CPAP. Best practice is to continue trilogy 
ventilator at prior productive settings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month use of a ventilator have been met. Therefore, we decided that the Plan 
has to pre-approve nine (9) month use of a ventilator (E0466).  
 
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 laboratory services (procedure codes 80307 and G0483) 
rendered on January 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
Healthcare Common Procedure Coding System (HCPCS) G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that laboratory drug testing, 
presumptive and definitive drug testing (procedure codes 80307 and G0483) were rendered on January 27, 
2023. However, the provided documentation did not describe/list the specific tests in the drug panel were 
ordered by the treating physician. Also, the records do not support that these codes were performed on 
1/27/2023 for the enrollee.  
 
We looked at this coder's review, the file, and Medicare rules. 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 laboratory services (procedure codes 80307 and G0483) rendered on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) additional visits for acupuncture 
treatments (97810, 97811, 97813, 97814). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the services. Our physician reviewer 
found the records show that the enrollee has not had any change in pain or functional scores and is being seen 
on an as needed basis with no active treatment plan. The enrollee has been receiving treatment 1 time per week 
on average, and pain has not been significantly changed. Progress is shown by less pain, improved activities, or 
more time between visits. The request is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fourteen (14) additional visits for acupuncture treatments (97810, 97811, 97813, 97814).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on December 6, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for an annual wellness visit. You say that the provider is in network with Humana. 
The Plan denied your request. The Plan says this provider is not a network provider with Humana. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on December 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin biopsy provided on January 23, 
2023. 
 
You asked the Plan to waive the copayment for the skin biopsy. You say that you were only in the office a 
short time. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 
copayment for in-network outpatient surgery provided at an outpatient hospital facility. 
 
You have been asked to pay a $390 copayment for the skin biopsy. This item/service falls within the in-
network outpatient surgery provided at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is 
less than the standard copayment, you only owe $335.39. Therefore, we decided that the Plan does not have to 
waive the copayment for the skin biopsy provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure (D7999) provided on 
March 8, 2023. 
 
You asked the Plan to pay for an unspecified oral surgery procedure (D7999). You say you had no other 
choice, but had to have this procedure done due to osteoporosis. The Plan denied your request. The Plan says 
this service is not covered under your contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified oral surgery procedure (D7999) provided on March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6209 and A9270 provided on February 24, 
2023. 
 
You asked the Plan to pay for procedure codes A6209 and A9270. 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. 
 
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 A6209 is not supported in the medical record. Specifically, code A6209 is a surgical 
dressing code and was billed without an A1-A9 modifier. Additionally, code A9270 is not payable when billed 
on an outpatient claim. Based on this information, we decided that Medicare rules for coverage of procedure 
codes A6209 and A9270 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes A6209 and A9270 provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36465 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation should be considered for 
reprocessing. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Providers must report services 
with the appropriate CPT code. We looked at the file and Medicare rules. The service at issue was provided within the global surgery period of 
code 37765 provided on March 6, 2023. We find that the required modifier suitable for separate payment was 
not billed. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 36465 billed for date of service 
March 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition meets IRF criteria 
and a lower level of care in skilled nursing cannot provide the total interdisciplinary team approach needed. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for admission to an IRF.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 30, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0143) and sales tax (S9999), purchased on 
April 1, 2023. 
 
You asked the Plan to pay for the walker and sales tax. You say that this should be covered. The Plan denied 
your request. The Plan says this was obtained through a provider that is not enrolled in Medicare. 
 
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 walker (E0143) and sales tax 
(S9999), purchased on April 1, 2023.
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 you need continued care because you are ill. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care. 
 
You asked the Plan to pre-approve custodial care. You say that your provided said you would need the 
requested care. The Plan denied your request. The Plan says personal care assistant is not covered under any 
condition. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve custodial care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L2 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria. You have not required hospitalization. There is no 
documentation of vertebral body height reduction, progression of height loss, kyphotic deformity, or 
documentation of pain scale scores. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L2 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication 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 corroboration of other plausible causes of the back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514).
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 additional routine transportation trips. You say that you need transportation 
to your 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 72 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.
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 the enrollee's condition is 
progressively worsening such that it qualifies them for this device. The Plan denied your request. The Plan says 
this device is considered unproven and 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 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 here 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.