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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs a ventilator due to 
repeated exacerbations and re-hospitalization. You say that although the enrollee has been on a BiPAP they are 
still having issues with exacerbation's which is causing them to be hospitalized. The Plan denied your request. 
The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has a BiPAP at home and has been compliant with use during sleep. However, there is no documentation of 
chronic carbon dioxide retention with an arterial blood gas analysis (ABG) done while stable. Also, there is no 
documentation of failure of BiPAP as an outpatient, with either a morning ABG showing persistent hypercarbia 
after using BiPAP or hypoxemia during sleep despite BiPAP and usual supplemental oxygen. The enrollee may 
benefit from the AVAPS mode of support during sleep as an outpatient, and this mode can be provided with a 
BiPAP. Therefore, a home ventilator system is not medically 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor, and the pneumatic appliance 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compressor, and the pneumatic appliance. You say that this is 
the only supplier in the enrollee's geographical area. The Plan denied your request. The Plan says enrollees 
must receive their care from a network provider. 
 
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 
the pneumatic compressor, and the pneumatic appliance to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visits, and related services provided 
on May 18, 2023, to May 25, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visits, and related services. You say that this is 
supported in the records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visits, and related services provided on May 18, 2023, to May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on February 13, 2023, through March 10, 2023. 
 
You asked the Plan to pay for the water circulating heat pad with pump (E0217) provided on. You say that the 
item was medically necessary. The Plan denied your request. The Plan says the item was not medically 
necessary 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump (E0217) provided on have not been met. Therefore, we 
decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided on 
February 13, 2023, through March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablations (64635) and (64636) provided 
on March 28, 2023 
 
You asked the Plan to pay for the radiofrequency ablations. The Plan denied your request. The Plan says the 
radiofrequency ablation 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 pay for the radiofrequency ablation. Our reviewer 
says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that although 
the enrollee has continued radicular pain, there is no indication that the enrollee has had two medial branch 
blocks, or what the response was. Also, it is impossible to say whether the improvement the enrollee 
experienced in July of 2022 was because of the radiofrequency ablation or the epidural steroid injection. Also, 
given the enrollee's continued radicular symptoms, it seems more likely that the relief was from the epidural 
steroid injection. Therefore, the enrollee does not meet the LCD coverage 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 the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pay for the radiofrequency ablations (64635) and (64636) provided on March 28, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment of dental pain  per visit (D9110), 
limited oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) 
provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed that this was infected and 
going to your brain so the services were medically necessary. 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 palliative treatment of dental pain  per visit (D9110), limited oral evaluation - problem focused 
(D0140), and intraoral - periapical first radiographic image (D0220) provided on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service May 31, 
2023.   
You asked the Plan to pay for procedure code 88374. You say that you would like the Plan to reconsider their 
denial of payment. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. The documentation did not show that the testing of 5 specimens would be 
inadequate for the enrollee in this case. Based on this information, we decided that Medicare rules for coverage 
of procedure code 88374 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88374 billed for date of service May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses provided on April 2, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the progressive lens. You say that you are requesting reimbursement for the 
lenses. The Plan denied your request. The Plan says there is no prior authorization, and the provider was out-of-
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 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 did not pre-approve the 
progressive lenses. We found no exception that would require the Plan to pay for the progressive lenses. 
Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on April 2, 2023, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a calf rest (E0995), and electronic connection (E2310). 
 
You asked the Plan to pre-approve a calf rest and electronic connection. You say that the items are medically 
necessary, The Plan denied your request. The Plan says the calf rests are unbundled, and the electronic 
connection is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
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 calf rest and electronic connection. 
Our reviewer says that the enrollee does not need these items. Our physician reviewer found the enrollee has 
sufficient strength and function in upper extremities to manage standard power drives. Calf rests are included 
with a group 3 power wheelchair. The requested calf rests are unbundled and not medically 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 a calf rest and electronic connection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a calf rest (E0995), and electronic connection (E2310).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve a LTACH admission. You say that a LTACH admission is the appropriate 
level of care for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
acute care.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no needs the enrollee has that cannot be met in the current setting and no 
therapeutic advantage is anticipated with a LTACH transfer. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 26, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 30, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that this is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 19, 2023, to February 14, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration for payment on this claim. The Plan denied your request. The Plan says a PCD is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery. Items that are used for a 
preventative service or function are excluded from coverage under the Medicare durable medical equipment 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on January 19, 2023, to February 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93922 provided on November 28, 2022. 
 
You asked the Plan to pay for procedure code 93922. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
93922. 
 
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 93922 is Limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior 
tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 
1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior 
tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels).  
We find that CPT code 93922 is not supported in the medical record. Specifically, the records provide no 
description for the limited bilateral physiological study to determine if the billing is correct. Based on this 
information, we decided that Medicare rules for coverage of procedure code 93922 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93922 provided on November 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation. The Plan denied your request. The 
Plan says the genicular radiofrequency ablation is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular radiofrequency ablation. 
Our reviewer says that the genicular radiofrequency ablation is not medically necessary. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablations are considered investigation and not 
medically necessary for the treatment of chronic knee 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 the genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the genicular radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 27, 2023. 
 
You asked the Plan to pay for OIVIT services. 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. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bi-level positive airway pressure (BiPAP) device with 
back-up rate (E0471) 
 
You asked the Plan to pay for a bi-level positive airway pressure device with back-up rate. You say that the 
item was medically necessary. The Plan denied your request. The Plan says the item was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a  bi-level positive airway pressure device with 
back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed 
with a diagnosis of OSA, it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a bi-level positive airway pressure device with back-up rate have not been met. Therefore, we decided that the Plan does not have to pay for a bi-level positive airway pressure (BiPAP) device with back-up 
rate (E0471)
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 3, 
2023, through March 4, 2023. 
 You asked the Plan to pay for SNF care. You say that the dates in question are covered under the MEDICARE 
Act. The Plan denied your request. The Plan says the enrollee did not need SNF care, and services could have 
been provided at a different level of care. 
 
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 pay for 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 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 pay for skilled nursing facility (SNF) care provided from February 3, 2023, through March 4, 2023.