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

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the Barostim Neo 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 the Barostim Neo device. Our reviewer 
says that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. Our physician reviewer found at this 
time, the Barostim Neo system would not be considered medically appropriate and necessary in your 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 the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (0266T, C1825).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy and fillings (D3310, D2330 x2) provided 
on September 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 12, 2023. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy and fillings (D3310, D2330 
x2) provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery, bone replacement graft, intravenous 
moderate (conscious) sedation/analgesia, and drugs or medicaments dispensed in the office for home use 
(D4260, D7953, D9239, D9630) provided on February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 osseous 
surgery, bone replacement graft, intravenous moderate (conscious) sedation/analgesia, and drugs or 
medicaments dispensed in the office for home use (D4260, D7953, D9239, D9630) provided on February 23, 
2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the healthy meals. 
 
You asked the Plan to pre-approve the healthy meals. You say that you are asking for reconsideration of 
coverage. The Plan denied your request. The Plan says that the service is not a covered benefit. The Plan says 
the plan does not offer Healthy Meals as an Essential Extra Benefit for a Chronic Illness. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the healthy meals have been met. Specifically, the record shows that you do have an eligible 
conditions that meets all the required criteria. Therefore, we decided that the Plan has to pre-approve the 
healthy meals. 
  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. The Plan denied your request. The Plan says a power wheelchair 
is not medically necessary for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 scooter. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the documentation available for review 
does not support that the enrollee requires a power mobility device to accomplish mobility related self-care 
tasks in the home. Our reviewer also found that there is no indication they are unable to use an alternative 
assistive device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex ultrasound of the legs (93971). 
 
You asked the Plan to pre-approve a duplex ultrasound of the legs. You say that this is medically necessary. 
The Plan denied your request. The Plan says there is no physician order. 
 
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 duplex ultrasound of the legs. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found no swelling was noted of the lower extremities on examination according 
to the provided documentation. Ultrasound of the lower extremities was part of the treatment plan, however. As 
you did not have any objective clinical findings or provocative testing results that would justify an ultrasound 
of the lower extremities, the documentation does not support this request for ultrasound.  
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 duplex ultrasound of the legs have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a duplex ultrasound of the legs (93971).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee is under your care for chronic 
respiratory failure secondary to severe restriction related to obesity hypoventilation syndrome. You also say 
that a similar device has been already considered, trialed, and proven to be insufficient to properly ventilate the 
enrollee. The Plan denied your request.  The Plan says a home ventilator is not medically necessary for the enrollee 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 the home ventilator. Our reviewer says 
that the  home ventilator is not medically necessary. Our physician reviewer found the enrollee has severe 
obesity, obesity hypoventilation syndrome, and heart failure with preserved ejection fraction. An arterial blood 
gas during a recent hospitalization was consistent with chronic CO2 retention. The enrollee previously had 
either BiPAP or a ventilator at home (unclear from the medical record) that was subject to the Phillips recall. 
The appeal letter indicates that the ventilator is needed for portability and battery back-up. The enrollee may 
benefit from BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator 
when used at settings that can be provided with a BiPAP. A backup battery and portability are not medically 
necessary in the treatment of obesity hypoventilation syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays and extractions (D7210, D0274) provided on 
June 20, 2023, to August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 bitewing x-rays and extractions (D7210, D0274) provided on June 20, 2023, to August 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf test billed for date of service January 5, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the clinical 
effectiveness has not been demonstrated.  
 
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 billed testing. Our physician reviewer 
found that the enrollee has end stage renal disease (ESRD) secondary to immunoglobulin A nephropathy with 
chronic kidney disease.  There were no records included that supported the use of the Omnigraf test.  The effectiveness of this test is 
also up to some speculation.  Notes included do not appear to justify the use of this test in this patient. 
Therefore, the request 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 the billed testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the OmniGraf test billed for date of service January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on October 17, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that the service provided was medically necessary. 
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 nursing facility care. 
provided on October 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 5, 2023. 

You asked the Plan to pay for the dental service. You say that you did not have dental x-rays on 10 teeth and 
you do not recall having any dental x-rays. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid $145 for dental services on March 1, 2023. On July 5, 2023, the Plan paid $605 for dental 
services. For the year of 2023 the Plan paid $750 ($145 paid + $605 paid) for dental services; therefore, your 
annual dental maximum benefit for the year of 2023 was exhausted on the date of service of July 5, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on September 5, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 00400. We decided that the Plan does not have to pay 
for procedure code 99140.  
 
You asked the Plan to pay for the anesthesia services provided on August 1, 2023. You say that medical 
records were provided for review. The Plan says that an appropriate modifier was not billed. 
 
We decided that the Plan has to pay for procedure code 00400.  
 
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 00400 is anesthesia for procedures on the integumentary 
system on the extremities, anterior trunk and perineum; not otherwise specified. We find that code 00400 is 
supported. The records show that code 00400 was performed by a different provider from code 01270, defined 
as anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified. 
There are no code edits for codes 00400 and 01270 that would require a modifier to identify separate and 
distinct procedures performed by separate providers. Therefore, we decided that the Plan has to pay for 
procedure code 00400.  
 
We also decided that the Plan does not have to pay for procedure code 99140. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99140. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on August 28, 2023. 
 
You asked the Plan to pay for a telehealth visit. You say that the enrollee was in a nursing home at the time the 
service was rendered. 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 telehealth visit 
provided on August 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
September 18, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you did not call for the 
ambulance. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation 
benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 18, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on September 18, 2023.
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 LTACH services. You say that the enrollee meets the criteria for an LTACH 
admission. The Plan denied your request. The Plan says that the enrollee is unstable for transfer to an LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the plan. Given there are offered alternatives, an 
LTACH admission 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 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 chronic care management services provided on August 31, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that these services were medically 
necessary. 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 chronic care 
management services provided on August 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Self-Administered drugs on July 23, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Self-Administered drugs on 
July 23, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.