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

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
February 1, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on November 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from December 27, 2022, to 
January 18, 2023. 
 You asked the Plan to pay for home health care. You say that you are appealing with the Notice of Admission. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 20, 2022. The NOA was not received by the Plan until April 24, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from December 27, 2022, to January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support.  It is intended to be used during 
activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung disease. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of lower leg neurostimulator electrode. 
 
You asked the Plan to pre-approve insertion of lower leg neurostimulator electrode. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that insertion of lower leg neurostimulator electrode are 
only covered for certain indications. 
 
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 insertion of lower leg neurostimulator 
electrode. Our reviewer says that the documentation does not support that the requested services are not 
medically reasonable or necessary. Our physician reviewer found the enrollee has urge incontinence, daytime 
frequency every 3 hours and nocturia times two. In 2019 the enrollee underwent urodynamics which did not 
reveal detrusor overactivity. The enrollee has failed behavioral therapy. Myrbetric caused ankle swelling and 
constipation with no change in voiding symptoms. The medical records do not document failed standard 
anticholinergic drug therapy or that the enrollee demonstrates intolerance to the anticholinergic drug therapy 
despite best attempts at management of the most common side effects of such therapy, such as dry mouth and 
constipation. 
 
Coverage for initial therapy with Posterior tibial neurostimulation via Urgent PC- 64566 requires 
documentation of failed standard anticholinergic drug therapy or that the patient demonstrates intolerance to 
the anticholinergic drug therapy despite best attempts at management of the most common side effects of such 
therapy, such as dry mouth and constipation. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of lower leg neurostimulator electrode have not been met. Therefore, 
we decided that the Plan does not have to pre-approve insertion of lower leg neurostimulator electrode.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on December 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 26, 2023. 
 
You asked the Plan to pay for the home visit. You say that you provide services to all patients in this facility. 
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 the home visit provided 
on March 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the service is separately billable. The Plan 
denied your request. The Plan says inpatient services were billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient. 
 
We find that CPT code 99223 was billed with 21, an inpatient place of service code. The enrollees claim 
information shows that the enrollee was receiving outpatient observation care at the time the services were 
provided. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for 
date of service February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93294 and 93296 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for codes 93294 and 93296. You say that your doctor is the only one who billed 
charges for this date of service. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 31, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for codes 93294 and 93296 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 93294 and 93296 billed for date of service 
July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for a non-invasive ventilator (NIV) 
is not medically necessary because the documentation does not support that this device meets but does not 
exceed your need.  
 
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. 
 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode or 
intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by 
a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800): "Ventilators fall under the Frequent and Substantial Servicing (FSS) payment 
category, and payment policy requirements preclude FSS payment for devices used to deliver continuous 
and/or intermittent positive airway pressure, regardless of the illness treated by the device. (Social Security Act 
1834(a)(3)(A)). This means that products currently classified as HCPCS code E0465, E0466, or E0467 when 
used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying 
medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement 
for any of the conditions described in this RAD LCD even though the ventilator equipment may have the 
capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or 
bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 
necessary." The LCD requires: "There must be enough detailed information in the medical record to justify the 
treatment selected." Provided records in this case do not provide adequate detailed information to meet 
Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
heart. 
 
You asked the Plan to pre-approve the CTA. You say that the imaging is needed as part of a work-up for a 
transcatheter aortic valve replacement (TAVR) procedure. The Plan denied your request. The Plan says similar 
imaging has recently been performed. The criteria for coverage for additional imaging have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record shows the enrollee had prior 
imaging done. A TAVR does not require repeat CTA imaging. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomographic angiography (CTA) of the heart.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 10, 2023, to March 10, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total allowed amount for the DME is $488.80. You are being asked to 
pay $97.76 ($488.80 x 20% = $97.76). Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment (DME) provided on February 10, 2023, to March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement identified with code D6010, interim 
implant abutment placement identified with code D6051, bone graft at time of implant placement identified 
with code D6104, and guided tissue regeneration identified with code D4267. 
 You asked the Plan to pre-approve implant placement, interim implant abutment placement, bone graft at time 
of implant placement, and guided tissue regeneration. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not covered. 
 
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 requested items or services are only 
covered for certain criteria and maximums. Review of the file shows that the enrollees dental benefits are 
limited to two implants and abutments placed per year. The enrollee previously received implants and 
abutments placed on March 29, 2023. This exceeds the benefit maximum per year. Therefore, codes D6010 and 
D6051 are not covered. Codes D6104 and D4267 are a secondary service done. Since the primary services are 
denied, these services are not covered. 
 
Therefore, we decided that the Plan does not have to pre-approve implant placement identified with code 
D6010, interim implant abutment placement identified with code D6051, bone graft at time of implant 
placement identified with code D6104, and guided tissue regeneration identified with code D4267.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
you need the device but cannot afford it. The Plan denied your request. The Plan says the request for continued 
use of non-invasive ventilator (NIV) is not medically reasonable and necessary. The documentation indicates 
that this device is being used solely for AVAPS-AE mode, and thus it is being used solely as a respiratory 
assist device. 
 
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. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have had a home ventilator since 
December 2022, when it was prescribed following a hospitalization. At that time, you were admitted with 
respiratory failure due to COPD exacerbation and exacerbation of HFpEF, with bilateral pleural effusions. 
ABG was consistent with acute on chronic hypercarbic respiratory failure. The etiology was felt to be a 
combination of COPD and obesity hypoventilation syndrome. There are no pulmonary function tests to confirm 
airways obstruction and assess severity. The ventilator is being used in AVAPS AE mode which can be 
provided by BiPAP. BiPAP has not been tried and shown to fail as an outpatient. Use of the ventilator from 
March 25, 2023, to April 23, 2023, shows the device was used at least 4 hours/day for 56.7% of days, which 
does not meet minimum Medicare criteria for compliance. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. The plan has approved the ventilator for 3 months to allow 
time for transition to BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that pembrolizumab is the best treatment option for the 
enrollee. The Plan denied your request. The Plan says that Keytruda is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is medically necessary. Our physician reviewer found that the requested use of Keytruda is FDA-
approved as a single agent for treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose 
tumors express PD-L1. The enrollee underwent treatment with Durvalumab with a question of progression. 
However, the enrollee had a good response to the treatment, also the brain mets that were detected just a few 
months after the initial diagnosis may have been present. Therefore, the requested use of Keytruda is safe and 
effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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 pay for the stair lift you purchased on August 15, 2022. 
 
You asked the Plan to pay for the stair lift. You say that you would like to be reimbursed for your expenses. 
The Plan denied your request. The Plan says stair lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair lift you purchased on August 15, 2022.