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

 
We decided that the Plan does not have to pay for the stationary bike purchased on March 16, 2020. 
 
You asked the Plan to pay for the stationary bike. You say that the item was necessary to continue 
rehabilitation. The Plan denied your request. The Plan says the item is not primarily medical in nature. 
Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the stationary bike purchased on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (J9022) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare guidelines and reference books do not support this drug to treat metastatic 
squamous cell carcinoma base of tongue with PD-L1 expression. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Tecentriq is not FDA 
approved for the treatment of head and neck cancer, such as tongue. Use is not supported by the medical 
literature or major drug compendia. The service is not reasonable or medically 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq (J9022) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SLCO1B1 gene testing (81328), a Level 9 Molecular 
Pathology Procedure (81408), and an unlisted genetic test (81479) provided. 
 
You asked the Plan to pay for SLCO1B1 gene testing, a Level 9 Molecular Pathology Procedure, and an 
unlisted genetic test. You say that these tests were medically necessary. The Plan denied your request. The Plan 
says this was not billed correctly. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures are covered when 
medically necessary and billed according to the above guidelines. 
 
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 SLCO1B1 gene testing, a Level 9 Molecular 
Pathology Procedure, and an unlisted genetic test. Our reviewer says that these procedures are not supported. 
Our physician reviewer found CPT 81479 is an inappropriate code to use for genetic testing for Parkinson-
Alzheimer-Dementia. Level 9 Molecular Pathology Procedures billed with 81408 are unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and are not covered.  
Genetic testing procedures submitted under 81328 are similarly not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SLCO1B1 gene testing, a Level 9 Molecular Pathology Procedure, and an 
unlisted genetic test have not been met. Therefore, we decided that the Plan does not have to pay for SLCO1B1 
gene testing (81328), a Level 9 Molecular Pathology Procedure (81408), and an unlisted genetic test (81479) 
provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on June 11, 
2020. 
 
You asked the Plan to waive the copayment for wound debridement. You say that you weren't admitted to the 
hospital, you were only seen in the wound clinic. You say that the wound clinic advised you that the service 
would be billed as an office visit.  The Plan denied your request. The Plan says the copayment applied 
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 $250 
copayment per visit for an outpatient surgery or procedure. 
 
You have been asked to pay a $250 copayment for wound debridement. Wound debridement falls within the 
"Outpatient hospital services" benefit category. Wound debridement is considered a surgical procedure that was 
billed by the hospital. 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 copayment for wound debridement provided on 
June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left shoulder continuous passive motion machine for 
the enrollee. 
 
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for the shoulder. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pre-approve a left shoulder continuous passive motion machine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Atezolizumab, Etoposide IV, Fosaprepitant 
IV, Ondansetron IV, and Dexamethasone for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug requires that the cancer has not grown or spread while on or 
following therapy with Tecentriq. 
 
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 the drugs. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found this enrollee with 
extensive stage small cell lung cancer has evidence of progression after 4 cycles of chemotherapy with 
atezolizumab. Continuation of atezolizumab after progression would not be clinically indicated. The service is 
not reasonable or medically 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Carboplatin, Atezolizumab, Etoposide IV, Fosaprepitant IV, Ondansetron IV, and 
Dexamethasone for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy), Panniculectomy (15830). 
 
You asked the Plan to pre-approve the Panniculectomy. You say that the gastro surgeon wants to do a hernia 
mesh at the same time as the tummy tuck/skin reduction and you would like this covered because you have 
suffered with the excess skin for many years. The Plan denied your request. The Plan says this request is 
considered cosmetic surgery and is not covered by the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-
approve excision, excessive skin and subcutaneous tissue (includes lipectomy), Panniculectomy (15830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FSHD1 and FSHD2 genetic testing. 
 
You asked the Plan to pre-approve genetic tests. You say that this testing may have direct implications on the 
enrollee's management. The Plan denied your request. The Plan says the denial of authorization for this testing 
is correct, because this testing will not directly impact treatment. 
 
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 genetic tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation submitted does not support that the requested FSHD1 and FSHD2 genetic 
testing would directly impact the health and management of the enrollee in this case. Testing which has no 
proven relation to the management and outcome of a medical condition of an enrollee is not a Medicare benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not 
have to pre-approve FSHD1 and FSHD2 genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 to pre-approve a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental. 
 
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 spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer device is experimental. More research is needed to show safety and efficacy. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
 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 preapprove a pneumatic compression device 
(E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee had stable vital signs, and had wound care. There are no 
identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a dependent assist level 
for bed mobility and transfers. She required varying assist with activities of daily living. Although there are 
identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy on a daily 
basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that knee scooters (crutch substitutes) are non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pay for continuous rental of the CPAP machine. 
 
You asked the Plan to pay for continuous rental of the CPAP machine. You say that the enrollee needs the 
CPAP. The Plan denied your request. The Plan says the enrollee is not compliant with the CPAP usage. 
 
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. The Compliance Report shows the enrollee is not using the CPAP 4 
hours per night on 70% of nights during a 30-day period. Based on this information, we decided that Medicare 
rules for coverage of continuous rental of the CPAP machine have not been met. Therefore, we decided that the 
Plan does not have to pay for continuous rental of the CPAP machine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for to cardiovascular risk assessment panel provided on April 14, 2020. 
 
You asked the Plan to pay for the test. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels is 
denied, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.  
 
We looked at the file and Medicare rules. The requested testing is non-covered per L36523. Based on this 
information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided 
that the Plan does not have to pay for to cardiovascular risk assessment panel provided on April 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography (77065) provided on January 17, 2020. 
 
You asked the Plan to pay for mammography. You say that this was medically necessary. The Plan denied your 
request. The Plan says the units billed exceed MUE. 
 
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 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of mammography have not been met. Therefore, 
we decided that the Plan does not have to pay for mammography (77065) provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitoring system for the 
enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are set doses of insulin that are not adjusted based on blood sugar readings. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary.  
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested system is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee is on multi-dose insulin. While not on a sliding scale, he is getting his dose adjusted based on 
interrogation of readings. The enrollee checks his blood sugar extensively. The monitor is indicated in this 
case, and is medically reasonable. 
 
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 system have been met. Therefore, we decided that the Plan has to pre-
approve a Freestyle Libre continuous glucose monitoring system for the enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the outpatient services provided on 
November 26, 2019. 
 
You asked the Plan to adjust the copayment for the outpatient services. You say that you were never in the 
hospital as an outpatient. The Plan denied your request. The Plan says you were charged this copayment 
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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities.  
 
You have been asked to pay a $295 copayment for the outpatient services. The outpatient services fall within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities 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 adjust the copayment for the outpatient services provided on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot receive adequate rehab at the 
skilled nursing facility. The Plan denied your request. The Plan says the enrollee has not completed his hospital 
course. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is at a contact guard assist for bed rolling, sitting up, and dressing. He is at a moderate assist 
for walking using a rolling walker, and at minimal assist for toileting. The enrollee does not require the 
intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.