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

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6, 2021, billed with 
codes 81401, 81225, 81227, 81226, 81230, 81231, 81291, 81335, 81355, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for 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 
April 6, 2021, billed with codes 81401, 81225, 81227, 81226, 81230, 81231, 81291, 81335, 81355, and 81328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve pneumatic compression device and appliances. You say that please see 
attached information supporting medical necessity for this enrollee to obtain a pneumatic compression pump 
for treatment of chronic lymphedema. The Plan denied your request. The Plan says the records do not support 
that the request is medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliances. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support evidence of chronic 
and severe lymphedema as identified by the documented presence of at least one of the following clinical 
findings: marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis 
lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, detailed measurements 
over time confirming the persistence of the lymphedema with a history evidencing a likely etiology, and no 
clear objective documentation indicating the patient is  unresponsive to other clinical treatment over the course 
of a required four-week trial. There are no objective limb measurements over time indicating failure of other 
conservative treatments in a four-week trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device and appliances have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliances (E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra (J3262). 
 
You asked the Plan to pre-approve Actemra. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Actemra. Our reviewer says that the 
requested drug, Actemra, is not medically necessary. Our physician reviewer found the requested use of 
Actemra is not Food and Drug Administration-approved for the enrollees diagnoses. The reviewer found that 
the requested use of Actemra for the enrollees diagnoses of polymyalgia rheumatica and other spondylosis, 
site unspecified is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Therefore, the reviewer found that the requested drug, Actemra, is not 
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 Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra (J3262).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device. 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G orthotic device. You say that the requested MyoPro 2 
Motion G orthotic device is medically necessary. The Plan denied your request. The Plan says the requested 
MyoPro 2 Motion G orthotic device 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 MyoPro 2 Motion G orthotic device. 
Our reviewer says that the requested MyoPro 2 Motion G orthotic device is not medically necessary. Our 
physician reviewer found the powered upper extremity range of motion assist device, elbow, wrist, hand, 
finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702) is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k). At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro 2 Motion G orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311).
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for an expandable controller, expandable controller harness, and electronic connection. Our Medical Director says that the documentation in the medical record states that the enrollee would be able to assist with cooking in the kitchen by elevating the wheelchair so he can reach the higher cupboards and be in a higher position to help with cooking on the stove. The documentation does not support that the requested expandable controller, expandable controller harness, and electronic connection were medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that your condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on April 28, 2022.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should not be charged this copayment because this was just a colonoscopy and was not diagnostic. 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 $250 copayment for each Medicare covered surgical center visit. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This item/service falls within the Medicare covered surgical center visit benefit category. This service was billed as a diagnostic colonoscopy and not a screening. 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 the diagnostic colonoscopy provided on April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided to the enrollee on March 10, 2021.
You asked the Plan to pay for the testing services. You say that the test was used to aid in the management of the enrollee. The Plan denied your request. The Plan says that the claim was submitted after the filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the testing services was not filed until March 18, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the lab testing services provided to the enrollee on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam intravenous immune globulin (IVIG). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee does not have a 
documented diagnosis of primary immune deficiency disease and the records do not document a medically-
accepted indication for Octagam. The criteria for coverage are not met and the requested IVIG 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Octagam intravenous immune globulin (IVIG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on July 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the registration staff and 
enrollee were not informed there should be an authorization obtained prior to the visit. The Plan denied your 
request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on July 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided June 2, 2022, to June 11, 
2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
Review of the file shows that this claim was billed with an incorrect type of bill. Type of bill 323 was billed. 
As the claim did not have the valid information, no payment can be made on this claim. Therefore, we decided 
that the Plan does not have to pay for the home health services provided June 2, 2022, to June 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered on September 21, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 45378 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 45378 is colonoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure). 
 
We find that CPT code 45378 is not supported in the medical record. Specifically, the records show that a 
screening sigmoidoscopy was performed and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient surgical services rendered on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that this lab test was ordered to determine whether or 
not the patient was at high risk for malignancy prior to performing an invasive biopsy or surgery. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 16, 2022, 
to March 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 16, 2022. The NOA was not received by the Plan until December 
15, 2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 16, 2022, to March 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 physiatry was consulted and recommends an IRF 
stay. The Plan denied your request. The Plan says an 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 there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 this patient 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 IR) admission and services.
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 the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs, gatlin midline mount for 
Quickie/quantum (K0108) track mounted claim for 3/4 tubing (K0108) repair or non-routine service for DME 
other than oxygen equipment requiring the skill of a technician, per 15 minutes (K0739). 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that this has been denied due to needing 
the history of all repairs made to the enrollee's current wheelchair. You have attached the repair verses 
replacement for review. The Plan denied your request. The Plan says the cost of repairs exceeds the cost of 
replacement of the wheelchair. 
 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. Medicare does not cover repairs when the expense for repairs 
exceeds the estimated expense for replacement of the wheelchair. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair repairs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair repairs, gatlin midline mount for Quickie/quantum 
(K0108) track mounted claim for 3/4 tubing (K0108) repair or non-routine service for DME other than oxygen 
equipment requiring the skill of a technician, per 15 minutes (K0739).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) and administration 
(90471) provided on September 1, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you had an appointment. You say that you had already 
received your first shingles vaccine. You say that you received your second shot that day assuming that it 
would be covered. You also say that you assumed since the first one was covered, this would be too. The Plan 
denied your request. The Plan says the singles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) and 
administration (90471) provided on September 1, 2022.