Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on November 8, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency sclerotherapy. 
 
You asked the Plan to pre-approve radiofrequency sclerotherapy. You say that radiofrequency sclerotherapy is 
medically necessary. The Plan denied your request. The Plan says the requested radiofrequency sclerotherapy 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 radiofrequency sclerotherapy. Our reviewer says that the requested radiofrequency sclerotherapy is not considered medically necessary in this 
case. Our physician reviewer found that the documentation does not meet the Medicare coverage criteria and 
does not support the medical necessity of the treatment in question. For the treatment to be considered 
medically necessary, the truncal vein to be treated must be at least 3 mm in diameter and the documentation 
must demonstrate that the patients symptoms are attributable to the vein in question. In this case, the enrollee 
has evidence of swelling of the whole left lower leg. There is documentation of a nonocclusive deep vein 
thrombosis (DVT) in the popliteal vein with insufficiency and there is documentation of a 6 cm mass in the 
popliteal fossa for which clinical correlation was recommended but is not addressed in the treatment 
rationale. The great saphenous vein at the level of the knee is absent with reflux noted only in an isolated 
segment at mid and distal calf in a very small, less than 3 mm diameter vein.  Lastly, the documentation 
suggests a plan for treatment of a single vein however the code in question codes for treatment of multiple 
veins. In summary, coverage criteria not met, and it is unclear that the enrollees current symptoms are due to 
the vein in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency sclerotherapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency sclerotherapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary in this case. Our physician reviewer found that the case file 
does not contain documentation of trial and failure of Remicade, Inflectra, or infliximab, and Stelara. The 
documentation does not support that Remicade, Inflectra, or infliximab, and Stelara, would likely be less 
effective and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular electrical stimulator (NMES) provided on 
December 12, 2022. 
 
You asked the Plan to pay for the NMES. You say that the claim was billed correctly. The Plan denied your 
request. The Plan says the NMES is not covered for the documented diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is 
limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the NMES have not been met. Therefore, we decided that the Plan does not have to pay for the 
neuromuscular electrical stimulator (NMES) provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation air-pulse 
generator system (HFCWO) (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation air-pulse generator system 
(HFCWO). You say that the item is medically necessary. The Plan denied your request. The Plan says the item 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that there must be a diagnosis of cystic fibrosis, 
bronchiectasis, or a qualified neuromuscular disease with well-documented failure of standard treatments to 
adequately mobilize retained secretions for a HFCWO to be considered 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 a high frequency chest wall oscillation 
air-pulse generator system (HFCWO). Our reviewer says that the item is not medically necessary. Our 
physician reviewer found there is no diagnosis of cystic fibrosis, bronchiectasis, or a qualified neuromuscular 
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 high frequency chest wall oscillation air-pulse generator system (HFCWO) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest 
wall oscillation air-pulse generator system (HFCWO) (E0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal genetic testing (81479) provided on 
September 21, 2022. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests must 
undergo an application and technical assessment process through the MolDX contractor. Only approved tests 
will be reimbursed consistent with the effective date of the coverage determination.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant Reveal testing have not been met. Specifically, we determined that the genetic testing at 
issue in this case has not been approved through the MolDX contractor. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal genetic testing (81479) provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99215 for date of service 
May 2, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the claim is not payable as billed. 
 
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 99215 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 high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 
 We find that CPT code 99215 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes D05.12 (intraductal carcinoma in situ of left breast and C50.922 (malignant neoplasm of 
unspecified site of left male breast without current pathological fracture). These diagnoses are not typically 
performed for an enrollee whose gender is male. The claim was not billed with an appropriate modifier for 
coverage. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the office visit billed with code 99215 
for date of service May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you need this device after an 
upcoming surgery. The Plan denied your request. The Plan says intermittent limb compression for the purpose 
of prevention of venous thromboembolism is a preventive service and not medically necessary. 
 
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 
pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyeglasses (V2781, V2750, V2799 and V2020) 
purchased on October 17, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are unhappy with how this claim has been 
handled, and these services should be paid. The Plan denied your request. The Plan says these eyeglasses were 
purchased from an out-of-network provider, and therefore no reimbursement may be provided. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 when they are received through the Plan's specified vendor. 
Any benefits received at a non-network optical provider are excluded from coverage and will not be paid. 
 
We looked at the file and the Plan's rules. The eyeglasses in this case were purchased from a vendor who is not 
the Plan's network optical provider. Based on this information, we decided that the Plan's rules for coverage of 
the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
eyeglasses (V2781, V2750, V2799 and V2020) purchased on October 17, 2022.  
 
Your complaint about how this claim was handled by the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for December 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 these services. Our reviewer says that procedure code 99285 is not supported. Our reviewer found the documentation supports medical decision making of moderate 
complexity with one or more chronic illnesses with mild exacerbation, two or more chronic illnesses, and an 
undiagnosed new problem with uncertain prognosis. The records do not support that decision making of high 
complexity was performed. 
 
We looked at this coder'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 pay for procedure code 99285 billed for December 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Anoro Ellipta 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this 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 pre-approve Anoro Ellipta
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided November 17, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
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) and segmental pneumatic appliances (E0673) provided 
November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that a kyphoplasty is medically necessary. The Plan 
denied your request. The Plan says the requested kyphoplasty is not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 kyphoplasty. Our reviewer says that 
the requested kyphoplasty is not considered medically necessary in this case. Our physician reviewer found that 
the enrollee has a four-year history of low back pain and leg weakness of unknown etiology. The enrollees 
pain was in the sacroiliac joint with radiation into the groin. She has had epidural steroid injections, physical 
therapy, oral steroids, and non-steroidal anti-inflammatory drugs. The enrollee had a magnetic resonance 
imaging scan of the lumbar spine on February 8, 2023. This showed multiple compression fractures that did not 
exhibit marrow edema, which is compatible with a remote injury. There was a disc bulge at L3-4 with 
moderate canal stenosis and moderate right and mild left neural foraminal encroachment. The physician 
believes the magnetic resonance imaging scan showed a subacute compression fracture at the superior endplate 
of L4. This is not stated in the official reading. This appears to be chronic rather than subacute or acute fracture. Therefore, the request does not meet the Medicare LCD 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 a kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 24, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported as billed. 
The Plan denied your request. The Plan says that the code used to report the services provided is not supported 
in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the medical records support that 
drugs from 18 different drug classes were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
definitive drug testing (G0482) provided on October 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
hemoglobin of 128 mg/dl and normal iron studies. The reported diagnosis is not supported by the records 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.