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

 
We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) 
therapy with humidifier. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that continued CPAP therapy is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mild obstructive sleep 
apnea (OSA) and was started on auto-titrating CPAP on April 20, 2023. The compliance reports for May 4, 
2023, to August 31, 2023 show use of the device for at least four hours per night for only two percent of the 
nights. This is not enough use for the device to be effective and does not meet the Medicare criteria for 
coverage. The continued CPAP therapy is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued continuous positive airway pressure (CPAP) therapy with humidifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6212 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for procedure code A6212. You say that the medical records substantiate the need 
for this item. The Plan denied your request. The Plan says procedure code A6212 is considered bundled and not 
separately payable.   
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 A6212 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6212 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6212 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6212 billed for date of service January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraorifice barrier (D3911), unspecified preventive 
procedure, by report (D1999), pulp vitality test (D0460), and treatment of root canal obstruction; non-surgical 
access (D3331) provided on March 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking for a re-evaluation of your case 
and to be reimbursed for the money that you paid. The Plan denied your request.  The Plan says your benefit for the  pulp vitality test has already been exhausted. The Plan also says that the 
dental services represented by codes D3911, D1999 and D3331 are not covered under your dental coverage. 
 
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, the dental services represented by 
codes D3911, D1999 and D3331 are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the intraorifice barrier (D3911), unspecified preventive procedure, by report 
(D1999), and treatment of root canal obstruction; non-surgical access (D3331) provided on March 8, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the pulp vitality test was exhausted on date of service March 8, 2023 for tooth #10. 
Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on March 
8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2022, billed with 
procedure code 27535. 
 
You asked the Plan to pay for inpatient-only services. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says this is an inpatient only code.  
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 27535. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on May 5, 2022, billed with procedure code 27535.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0888 billed for date of service March 19, 
2023. 
 
You asked the Plan to pay for procedure code A0888. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 A0888 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code A0888 is not covered by Medicare. Based on this information, we decided that Medicare rules 
for coverage of procedure code A0888 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0888 billed for date of service March 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93042 billed for date of service November 20, 2022. 

You asked the Plan to pay for procedure code 93042. You say that the claim was billed correctly and should be paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 99291. Maximus partially overturned the Plan's denial. The Plan requested a reopening and indicated they have approved payment for procedure code 99291.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93042 billed for date of service November 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 72-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says the requested number of 
trips exceeds the enrollee's transportation benefit. 
 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 trips for routine transportation beyond the Plan's 
72-trip limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided from March 1, 2023, 
to April 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the therapy services. You say that you were informed that authorization was not 
required. The Plan denied your request. The Plan says 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 at issue in this case is not a network provider with the Plan. 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 therapy services. Our reviewer says that the services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
indicate that the services provided were of an emergent or urgent manner or need. There is no indication that 
the member could not get prior authorization for the services or that she could not receive equally beneficial 
services from an in-network provider. The requested outpatient physical therapy services were 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 therapy services have not been met.  
 
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 pay for the therapy services. Therefore, we decided that the Plan 
does not have to pay for physical therapy (PT) services provided from March 1, 2023, to April 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services performed on August 27, 2022, through 
September 5, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the inpatient services should be covered 
because they were billed correctly. The Plan denied your request. The Plan says that the inpatient services are 
denied because the charges were not submitted on a Center for Medicare and Medicaid Services (CMS)/Health 
Care Finance Administration (HCFA) 1500 claim form. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We found that the case file does not include the claim image for the inpatient 
services. The case file does not contain proof that these services were submitted for payment by the provider on 
an incorrect form. Without evidence of how the claim was submitted, we are unable to determine if the Plan's 
rationale for denying the inpatient services is accurate. Therefore, we decided that the Plan has to pay for the 
inpatient services performed on August 27, 2022, through September 5, 2022.  
 
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 Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 24, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the medical records support payment. The Plan 
denied your request. The Plan says these services were not authorized. 
 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 May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 10, 2023, billed with 
procedure code G0453-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this add on code was not billed with an 
appropriate primary procedure code.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
practitioner services provided is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for practitioner services provided on May 10, 2023, billed with procedure code 
G0453-59.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this drug is not being supplies as provider buy-and-bill so is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Leqvio.  
 
Benefits for Leqvio may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 7, 2023, and billed with codes 87481, 87640, 87653, 87798, 87641, 87496, 87529, 87551, 
87661, 87541, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on April 7, 2023, and billed with codes 87481, 87640, 87653, 87798, 87641, 87496, 87529, 
87551, 87661, 87541, and 87798.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT) (77370, 77373). 
 
You asked the Plan to pre-approve SBRT. You say that the requested treatment is medically necessary. The 
Plan denied your request. The Plan says that there is no good evidence that SBRT treatment is safe or effective 
for the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT delivering high fractional doses in 2-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. There is abundant data on the use of SBRT for Stage I and II (node 
negative) non-small cell lung cancer (NSCLC). Based on a satellite nodule in proximity of main tumor (~4 
centimeters (cm) which would be T2) he would be staged as T3N0, IIB. The American Society for Radiation 
Oncology (ASTRO) model policy states that SBRT is indicated for primary malignant tumors of the lung in 
enrollees where the general medical condition (namely, the performance status) justifies aggressive local 
therapy. From NCCN guidelines (version 3.2023) for enrollees with T3N0 NSCLC (based on tumor size as 
opposed to invasion into chest wall or pericardium), the guidelines recommend definitive radiotherapy (RT), 
preferably stereotactic ablative body radiotherapy (SABR) with SABR being synonymous with SBRT. The 
guidelines state that for tumors >5 cm, selected larger isolated tumors can be treated safely if normal tissue 
constraints are respected. This enrollee has a <5 cm tumor with a satellite nodule. The decision is favorable as 
SBRT for select enrollees with T3N0 NSCLC is in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiotherapy (SBRT) (77370, 77373).  
 
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 chiropractic services provided on April 02, 2023, to April 13, 
2023. 
 
You asked the Plan to pay for chiropractic services. You say that you never had to call for prior authorization. 
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 chiropractic services 
provided on April 02, 2023, to April 13, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services billed for dates of service from July 13, 2022, to 
July 29, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that the home health services at issue 
have been miscoded as "early period." The Plan states that the enrollee received previous home health services 
fewer than 60 days prior to the date of admission for the services at issue. However, the Plan has not provided 
documentation of the previous home health period of care. It is the Plan's responsibility to support its denial 
with evidence. In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, we 
decided that the Plan has to pay for home health services billed for dates of service from July 13, 2022, to July 
29, 2022.  
 
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 Group 3 heavy-duty power wheelchair (K0850) and 
related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related supplies. You say that the 
requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for a Group 3 power wheelchair have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 heavy-duty power wheelchair (K0850) and related accessories and features.