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

 
We decided that the Plan does not have to pay for the office visit provided on February 07, 2023. 
 
You asked the Plan to pay for the office visit. You say that you want this claim reprocessed and paid. 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 office visit provided 
on February 07, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427, A0425) provided on December 6, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says that the payment for these services is included in the 
payment to the facility. 
 
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 has provided no documentation to support that these 
services would be included in the payment to any facility. There is no evidence that the enrollee maintained 
inpatient status with one facility on the date in question or that the enrollee was transported to a different 
building within the same hospital/facility group. These services are not supported as being inpatient 
transportation. The Plan's denial is not substantiated, and these services should be separately payable based on 
the documentation provided. Therefore, we decided that the Plan has to pay for ambulance services (A0427, 
A0425) provided on December 6, 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 pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are 
requesting the denial to be overturned so the enrollee can begin the compression therapy in the home. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
November 2, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Patient-Driven Payment Model (PDPM) score billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support that the enrollee had an active 
diagnosis of pneumonia and diabetes mellitus that required a treatment plan that was signed by a physician. 
The 1st and 3rd alphanumeric character in the PDPM were not correct. The partial adjustment to PDPM 
LAQD1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from November 2, 2021, to November 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral therapeutic SI joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a bilateral 
therapeutic sacroiliac joint injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the left SI joint injection is not 
medically necessary because the diagnostic injection had only 50% pain relief for 10 days. Additionally there 
was no diagnostic injection on the right side, therefore the therapeutic injection is not 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bilateral therapeutic SI joint injection.
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 device is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 the enrollee has 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 targeted tidal volume, volume assured pressure support 
(TTV-VAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support (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 (LCD) 33800: "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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the enrollee has failed at least 4 weeks of 
conservative care with a basic lymphedema pump. Additionally, the documentation doesnt support that the 
enrollee has physical findings consisting of truncal, abdominal or chest edema. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric pull-ups and non-sterile gloves. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve bariatric pull-ups and non-sterile 
gloves.
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 24-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 enrollee's 
transportation benefit has been exhausted. 
 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 24 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 
24-trip limit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is unsafe to discharge the enrollee home. The Plan 
denied your request. The Plan says the SNF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services (74176) provided on November 30, 2022. 
 
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says that this 
provider is not eligible for payment for the professional component of these services. 
 
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. The Plan argues that this provider is not eligible for payment for the professional 
component of these services. However, the Plan has not provided documentation supporting that this provider 
is not payable for these services. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the radiology services (74176) provided on November 30, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need new top dentures because you are 
missing front teeth from a previous bridge. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2021. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture (D5213) and 
mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99360 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 99360. You say that you disagree with the denial. 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 99360 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 99360 is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99360 billed for date of service January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
request is considered a duplicate service. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an electric scooter. The enrollee's scooter serves the same purpose as the 
requested wheelchair. The records do not show that the enrollee's current device is of irreparable damage. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning belt (E0978), manual swingaways 
(E1028), electronic connection device (E2311), harness (E2313), expandable controller (E2377), and attendant 
control (E2331) for a power mobility device.  

You asked the Plan to pre-approve wheelchair components. You say that this is medically necessary. The Plan 
denied your request. The Plan says these components are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve wheelchair components. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested electrical accessories are not medically necessary as the enrollee has 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the wheelchair base. Additionally, there is not a medical reason that the enrollee would require a duplicate 
positioning belt or strap and retractable/removable mounting hardware. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair components have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positioning belt (E0978), manual swingaways (E1028), electronic connection 
device (E2311), harness (E2313), expandable controller (E2377), and attendant control (E2331) for a power 
mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an out-of-
network provider on December 14, 2022. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you do not agree with the cost 
sharing. 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 a 10% 
coinsurance for out-of-network Medicare-covered physician specialist services. 
 
You have been asked to pay a $18.32 coinsurance for the office visit ($183.19 allowed amount x .10 = $18.32 
rounded up). This item/service falls within the physician/practitioner services, including doctors office visits 
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. 
Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit provided by an 
out-of-network provider on December 14, 2022.