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

 
We decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins (37765). 
 
You asked the Plan to pre-approve Stab phlebectomy of varicose veins (37765). You say that the requested 
Stab phlebectomy of varicose veins (37765) is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested Stab phlebectomy of varicose veins (37765). 
 
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 Stab phlebectomy of varicose veins 
(37765). Our reviewer says that the enrollee does not meet criteria for the requested Stab phlebectomy of 
varicose veins (37765). Our physician reviewer found coverage criteria require that for stab phlebectomy to be 
considered medically necessary, the veins in question must be greater than 3mm in diameter and can be 
performed concomitant with or staged with saphenous vein treatment. In this case, no tributary veins larger 
than 3mm is documented. Additionally, the one tributary vein that is commented on in the duplex examination, appears to be in communication with a refluxing small saphenous vein. It is not clear from the medical record 
which territory of veins are being considered for treatment. A photo or more detailed exam/rationale that 
includes vein sizes and location may be helpful as the current documentation does not meet coverage criteria 
and it is not clear if the planned stab phlebectomy is in the territory of a refluxing saphenous vein. Typically 
stab phlebectomy of tributary veins in communication with a refluxing saphenous vein is not covered unless 
the saphenous reflux is treated first or, depending on the provider and health plan, at the same time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stab phlebectomy of varicose veins (37765) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins (37765).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for procedure code 77061. 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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 04, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. 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 nursing facility care 
provided on January 04, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (96372) provided on December 14, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, this service has a status 
indicator of Q1 and was billed on the same date of service as code 99284 which has a status indicator of "V". 
Code 96372 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay 
for emergency room services (96372) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that an osteogenesis stimulator is 
medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
device that provides electrical stimulation for bone repair, (code E0747) osteogenesis stimulator, electrical, 
noninvasive, other than spinal applications, does not meet the requirements for approval. 
 
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 an osteogenesis stimulator. Our 
reviewer says that the requested osteogenesis stimulator is not considered medically necessary. Our physician 
reviewer found that the enrollee was being treated for a nondisplaced fracture of the fifth metatarsal bone on 
the right. The enrollee presented with continued swelling and is using knee roller crutches and is partial weight-
bearing when not on roller. The enrollee has less pain. The exam reveals an absent right posterior tibial pulse 
and edema. There is still swelling at the right 5th metatarsal base. However, detailed documentation is not 
evident regarding a passage of at least 90 days since the fracture with serial x-rays corroborating non-healing. 
No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of 
this request as an exception. Therefore, the requested osteogenesis stimulator, electrical, noninvasive, other 
than spinal applications does not meet the Medicare coverage 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 an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on October 12, 2022. 
 
You asked the Plan to pay for shingles vaccine. You say that you were advised by customer service that this 
would be covered. The Plan denied your request. The Plan says this immunization is not covered by Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine. 
Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on October 12, 2022.  
 
Benefits for shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights. 
 
Your complaint about receiving inaccurate advice from the Plans customer service department 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the CardioMEMS HF system is 
medically necessary. The Plan denied your request. The Plan says the CardioMEMS HF system 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 a CardioMEMS HF system. Our 
reviewer says that the CardioMEMS HF system is not medically necessary. Our physician reviewer found the 
CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a 
sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. You say that you really need a power scooter 
because you have taken several falls, currently use a walker, and still fell. You also say that you do not feel safe 
going out or to your doctor's appointments. The Plan denied your request. The Plan says the medical 
information provided is insufficient to determine if you meet the Medicare rules for a power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that all of the criteria in the Medicare rules section of this 
letter must be met in order for a POV to be 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 a group 1 standard POV. Our reviewer 
says that you do not meet the coverage criteria for a group 1 standard POV. Our physician reviewer found 
powered mobility devices are necessary for use in the home. You have normal neurological function. Our 
reviewer also found that it is unclear why a powered device is necessary rather than a manual wheelchair. 
 
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 group 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection 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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that an epidural steroid injection is not indicated for facet arthropathy. 
Diagnostic medial branch blocks are used to make the diagnosis of facet arthropathy. The requested procedure 
is NOT medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454 for date of service December 20, 
2022. 
 
You asked the Plan to pay for procedure code 64454. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for code 64454 is listed to specific 
diagnosis codes.  
 
We looked at the file and Medicare rules. Code 64454 was billed with diagnosis codes G89.29 and M17.0. 
These diagnosis codes are not listed as covered diagnosis codes for this procedure code. The claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 
64454 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 64454 
for date of service December 20, 2022.
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 a CGM. You say that the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
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 a CGM. Our reviewer says that the 
enrollee does not meet criteria for the requested CGM. Our physician reviewer found the absence of any insulin 
mention in the office note from April 25, 2023, suggests the enrollee is not taking or prescribed insulin. There 
is no documented history of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for procedure code 76641. You say that these services are supported as billed. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E1002, E2361, E0955, E2607, E0995, E1028, and 
K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option and 
additional items and accessories. You say that the enrollee requires a group 3 power wheelchair with single 
power seat function. You also say that without this equipment with power seat function, the enrollee is at risk 
for skin breakdown and further deterioration of health. The Plan denied your request. The Plan says the request 
for K0856 group 3 power wheelchair with single power option is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power seating 
system, tilt only, may be covered if certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 standard power wheelchair 
with single power option and additional items and accessories. Our reviewer says that the enrollee does not 
meet the coverage criteria for a group 3 standard power wheelchair. Our physician reviewer found the enrollee 
does not use intermittent catheterization, have a high risk for skin breakdown, or have spasticity. Our reviewer 
also found that the enrollee is able to drive, so they can use a standard joystick. 
 
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 group 3 standard power wheelchair with single power option and additional 
items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with single power option (K0856) and additional items and accessories 
(codes E1002, E2361, E0955, E2607, E0995, E1028, and K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from obesity hypoventilation syndrome with restrictive disease 
and cor pulmonale.  The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability 
and failure of such a device has not been documented. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 75710. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 75710. Any codes which are not listed are considered not medically necessary for 
code 75710. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 75710 have not been met. Specifically, this claim was submitted with diagnosis 
code I15.0, which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for procedure code 75710 billed for date of service 
November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 11, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. 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 nursing facility care 
provided on January 11, 2023.