Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on 
November 10, 2022. 
 You asked the Plan to pay for the Cala Trio nerve stimulator leads. You say that the enrollee has been using the 
Cala Trio device and seeing improvement and control over their hands' essential tremor. The Plan denied your 
request. The Plan says the denial of the Cala Trio nerve stimulator device was appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that where electric nerve stimulation is employed to treat 
motor function disorders, no reimbursement may be made for the stimulator or for the services related to its 
implantation since this treatment cannot be considered 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 pay for the Cala Trio nerve stimulator leads. Our 
reviewer says that the Cala Trio tremor nerve stimulator leads are not medically necessary. Our physician 
reviewer found there is insufficient evidence in the literature that this device is effective for the enrollee. Our 
reviewer also found that the requested leads for the Cala Stimulator are not medically necessary as the Cala 
Trio stimulator is not the standard of care for this enrollee's tremor according to current guidelines.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Cala Trio nerve stimulator leads have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cala Trio nerve stimulator leads (K1019) provided on November 10, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had back surgery and you do not feel you are 
ready to be sent home because you are still in a lot of pain and your home is not conducive to your recovery. 
You feel you need IRF services for at least one week. The Plan denied your request. The Plan says the 
requested IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Bupivacaine injection provided on March 2, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that you have billed the service at issue correctly. The 
Plan denied your request. The Plan says that payment for the service at issue is included in the global surgery 
package for procedure code 62323. 
 
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 not documented that procedure code 62323 was billed 
or paid for the same date of service. It is the Plan's responsibility to support its denial with evidence. In this 
case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided that the Plan has 
to pay for Bupivacaine injection provided on March 2, 2023.  
 
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 pay for the eyewear provided on February 20, 2023. 
 You asked the Plan to pay for the eyewear. You say that you do not like the eyeglasses you purchased and 
would like the payments to be retracted. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
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 a $150 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $150 allowance, which exhausted the 
benefit. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
22, 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 December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77525). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton beam therapy proton beam therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon the provided records it is not plausible that proton therapy 
would provide a clinically meaningful benefit over a well-designed Intensity-modulated radiation therapy 
(IMRT) plan. While not experimental, its potential benefit over non-proton-based radiation is an investigational question. Thus, proton therapy is not necessary as it would not meet ASTRO or NCCN criteria and therefore 
would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77525).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the comprehensive inherited cardiovascular panel provided 
May 3, 2021. 
 
You asked the Plan to pay for  the laboratory service. You say that please have a look at the attachment and 
reconsider the charges that were previously denied The Plan denied your request. The Plan says this service is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Screening asymptomatic patients for cardiovascular risk is statutorily 
excluded by Medicare. Also, per the Medicare Benefit Policy Manual, Chapter 15, Section 280, Preventive and 
Screening Services, screening genetic testing is not a covered benefit. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for  the comprehensive inherited cardiovascular panel provided May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 26, 2022, billed with 
codes 87486, 87496, 87498, 87581, 87640, 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are submitting the medical records, so 
kindly process the claim towards payment. The Plan denied your request. The Plan says panel testing should be 
billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 26, 2022, billed with codes 87486, 87496, 87498, 87581, 87640, 87798.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate and if failed, 
zoledronic acid first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of an oral 
bisphosphonate and if failed, zoledronic acid first before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the 
Plans required drug(s) would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
15, 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 December 15, 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 the home ventilator. You say that this ventilator 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 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 the home ventilator. Our reviewer says 
that the requested device is not medically necessary. Our physician reviewer found the enrollee could be treated 
with a BiPAP machine and failure of such a device has not been documented in the records. 
 
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 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 pay for therapeutic procedures, and related services provided on 
September 29, 2022. 
 
You asked the Plan to pay for therapeutic procedures, and related services. You say that these services were 
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 therapeutic procedures, 
and related services provided on September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device, bi-level pressure capability, 
with back-up rate feature, used with noninvasive interface (E0471) provided on February 4, 2023. 
 
You asked the Plan to pay for the respiratory assist device. You say that this device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says this device is not covered when billed with a 
diagnosis of obstructive sleep apnea (OSA). 
 
The Plan must follow Medicare rules. Medicare rules say that a bi-level positive airway pressure device with 
back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is obstructive sleep apnea (OSA). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory assist device have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory assist device, bi-level pressure capability, with back-up rate feature, used with 
noninvasive interface (E0471) provided on February 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided August 
11, 2022, to August 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the Plan has coverage for DME, 
and the charges are medically necessary, therefore all charges should be paid in full. 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) provided August 11, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump 
(A4223) and disposable drug delivery system (A4305) provided from November 1, 2022, to November 8, 
2022. 
 
  You asked the Plan to pay for the infusion supplies and disposable drug delivery system. You say that your 
department requires reimbursement for the unpaid charges that are indicated on the claims that include the 
necessary supplies and service charges applicable to the medication being administered to the enrollee. The 
Plan denied your request. The Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that disposable drug 
delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices 
because they do not meet the Medicare definition of durable medical equipment. 
 
We find that CPT code A4223 is not supported in the medical record. Specifically, this code is not supported as 
it has a status indicator of X, meaning the code is statutorily excluded from coverage. Based on this 
information, we decided that Medicare rules for coverage of the infusion supplies and disposable drug delivery 
system have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies 
not used with external infusion pump (A4223) and disposable drug delivery system (A4305) provided from 
November 1, 2022, to November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on March 6, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 20610 provided on March 6, 2023. Separate payment cannot be made for 
procedure code J3490. Based on this information, we decided that Medicare rules for coverage of procedure 
code J3490 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 
J3490 provided on March 6, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 5, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the provider 
type is not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
December 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you were 
treated on the scene and not transported to the hospital, but you were later admitted to the hospital on 
January 1, 2023. You say that you were not aware you would have to pay for not being transported. The Plan 
denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without 
transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on December 31, 2022.