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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a high frequency chest wall oscillation system to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio device (external upper limb tremor 
stimulator). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says items must be reasonable and necessary for the diagnosis or treatment of illness or injury 
to improve the functioning of a malformed body member. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence in the literature that this device is effective for the patient's tremor. The 
requested Cala device is not the standard of care for your tremor according to current guidelines.   
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Cala Trio device (external upper limb tremor stimulator).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on August 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter". 
 
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 use of code 99214 is not supported by the records provided. Our reviewer found that the enrollee presented with a urinary tract 
infection. The medical decision-making does not warrant a moderate level of complexity. 
 
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 the services (99214) provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on July 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter". 
 
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 use of code 99214 is not supported by the records provided. Our reviewer found that the enrollee presented with left knee pain. The 
medical decision-making does not warrant a moderate level of complexity. 
 
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 the services (99214) provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring active non-pneumatic compression 
garment system. 
 
You asked the Plan to pre-approve the system. You say that this si medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this item is helpful for treatment of the enrollee's 
health problem. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has chronic venous insufficiency with a healing ulcer. The requested device has not 
been shown to be as effective to standard devices.  
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Koya Dayspring active non-pneumatic compression garment system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma test (81529) provided June 14, 
2023. 
 
You asked the Plan to pay for the laboratory testing. You say that your claim for the DecisionDx-Melanoma 
test was denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The 
Plan says the enrollee did not meet the coverage criteria for the DecisionDx-Melanoma test. 
 
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 laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the DecisionDX-Melanoma testing was not medically reasonable and appropriate in this 
clinical 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 the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the DecisionDx-Melanoma test (81529) provided June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection. 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not a medical need to control the requested 
power options through the joystick. 
 
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 electronic connection. Our reviewer says that the requested electronic connection is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided records show that the enrollee's upper extremity strength and 
functional ability as shown by independent in feeding and bathing and grooming support that the enrollee can 
control any power options through their own switches. Therefore, the reviewer found that the requested 
electronic connection is not medically reasonable or 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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual adult size wheelchair (E1161) and accessories 
(E0954, E0955, E0971, E0973, E0990, E1028, E2201, E2203, E2231, E2609, E2617, K0040, K0108). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that there is documentation 
that the custom wheelchair is necessary for the enrollee's care. The Plan denied your request. The Plan says 
Medicare does not cover durable medical equipment in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual adult size wheelchair (E1161) and 
accessories (E0954, E0955, E0971, E0973, E0990, E1028, E2201, E2203, E2231, E2609, E2617, K0040, 
K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. Although the enrollee is on a medication that can cause low blood 
sugars, we are not told of any problematic low blood sugars. Hence although the CGM may help the enrollee, 
the coverage criteria are not met. If the enrollee is unable to use a fingerstick meter or is started on insulin, this 
data should be submitted and the case re reviewed. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 direct skilled nursing services and 9 home health aide 
visits. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation shows that the enrollee has functional impairments however does not specify any acute 
clinical status, medication, or plan of care changes (vitals within normal limits, no skin breakdown or new 
medications) or complex wounds thus the records do not show that 9 additional home health skilled nursing 
visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. 
 
Clinical documentation does not specify any plan of care requiring the treatment of skilled professional staff. 
The requested services do not meet the definition of home health aide services as per Sections A, B, C, D & E 
of Section 50.2 thus 9 additional home health aide visits are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 direct skilled nursing services and 9 home health aide visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99306 and 99497 for date of service June 3, 
2023, to June 4, 2023. 
 
You asked the Plan to pay for procedure codes 99306 and 99497. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 procedure code 99306 is initial nursing facility care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 45 minutes must be met or exceeded. 
The CPT Code Manual definition of code procedure code 99497 is advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
We find that CPT codes 99306 and 99497 are not supported in the medical record. Specifically, the 
documentation does not support the total time providing the initial nursing facility care services. This means 
code 99306 cannot be verified. The submitted medical records do not include documentation of an advance 
care planning including the explanation and discussion of advance directives such as standard forms (with 
completion of such forms, when performed), by the physician or other qualified health care professional; first 
30 minutes, face-to-face with the patient, family member(s), and/or surrogate; therefore, code 99497 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 99306 and 
99497 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99306 
and 99497 for date of service June 3, 2023, to June 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
condition. 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 Otezla.  
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says services can be provided in a skilled 
nursing facility (SNF). 
 
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 the enrollee, is a 72 year old male with coronary artery disease and diabetes who was 
admitted to the hospital with an ST elevation MI and cardiogenic shock. He suffered anoxic brain injury, had 
an AICD placed. He has a leukocytosis of 17. He is not on the ventilator, does not have a PEG, and appears to still require acute care services such that a transfer is not safe. He does not meet LTACH admission 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation device 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve an HFCWOD. 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 HFCWODs have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high-frequency chest-wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high-frequency chest-wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high-frequency chest-wall oscillation device (HFCWOD) (E0483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient care and 
is currently unstable to 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 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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The requested 
service cannot be recommended as the elements of the coverage rules are not satisfied. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for extremity venography described 
by code 36005 performed on date of service July 12, 2023. 
 
You asked the Plan to pay for 36005. You say that 36005 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 36005 is denied because it was billed without a 
required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifiers -LT and -RT should be used whenever 
a procedure that can be performed on the right or left side is performed on only one side. 
 
We looked at the file and Medicare rules. In this case, we have confirmed code 36005, defined as injection 
procedure for extremity venography (including introduction of needle or intracatheter), was billed without a modifier indicating laterality. Records indicate 36005 was performed on an anatomic structure that can be 
distinguished as left or right. Therefore, a modifier indicating laterality is required. Based on this information, 
we decided that Medicare rules for coverage of 36005 have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection procedure for extremity venography described by code 36005 performed 
on date of service July 12, 2023.