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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) and related 
accessories. 
 
You asked the Plan to pre-approve the group 3 PWC and related accessories. You say that you are unable to 
walk and are currently in a wheelchair. You say that you have very limited strength in your legs and have 
multiple sclerosis. The Plan denied your request. The Plan says Medicare does not cover durable medical 
equipment (DME) in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the group 3 PWC and related accessories are being requested for use in a SNF. Therefore, 
we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) and related 
accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical criteria for an IRF admission have been 
met. 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 the enrollee was admitted for a hip fracture after a fall. Medical problems are stable 
and there are no complex nursing or rehabilitation needs.  
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. The Plan denied your request. The Plan says the clinical 
effectiveness for small bowl cancer has not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Vectibix. Our physician reviewer found 
that you have metastatic duodenal adenocarcinoma with bone metastasis. The requested use of Vectibix is not 
FDA approved for your condition. The use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported 
or not recommended in any of the compendia. The documentation does not support that the requested drug is 
safe and effective and otherwise 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 Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not have 
complex medical needs. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for weakness and rhabdomyolysis. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRIs and CT scan provided May 25, 
2022, to June 20, 2022. 
 
You asked the Plan to waive the copayment for MRIs and a CT scan. You say that the copayments are too high. 
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 $100 copayment 
for an MRI. Your contract with the Plan also clearly says that you must pay a $100 copayment for a CT scan.  
 
You have been asked to pay a $100 copayment for each MRI and CT scan. The total you owe is $300 ($100 x 3 = $300). 
These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies. 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 MRI and CT scan provided May 25, 2022, to June 20, 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 a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
TTV-VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. You could be treated with a BiPAP machine with AVAPS capability. The plan has 
indicated coverage for such a device is available upon request. 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 (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening digital breast tomosynthesis, bilateral and breast 
mammography provided on September 17, 2021. 
 
You asked the Plan to pay for screening digital breast tomosynthesis, bilateral and breast mammography. You 
say that the patient had multiple scans on this date of service. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 20, 2021 and June 22, 2022. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for screening digital breast tomosynthesis, bilateral and breast mammography have not been met. Therefore, we decided that the Plan does 
not have to pay for screening digital breast tomosynthesis, bilateral and breast mammography provided on 
September 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 skilled nursing visits and 13 physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
You also say that they are helping you. The Plan denied your request. The Plan says you are not making 
progress with therapy. The Plan also says that the requested services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation indicates you are in a wheelchair. The reviewer found there is no clear documentation 
that you require skilled therapy or medical assessment (skilled nursing). Therefore, the reviewer found that the 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 skilled nursing visits and 13 physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 76705 billed for date of service February 18, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 2, 2022, to 
February 15, 2022. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says the Notice of Admission (NOA) was not billed with the correct admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that for each admission to home health, the HHA 
notifies Medicare systems via submission of a Notice of Admission (NOA). The admission date on the NOA 
must always match the from date.  
 
We looked at the file and Medicare rules. The submitted NOA was billed with an admission date that does not match the from date. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided from February 2, 2022, to February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on 
June 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for FoundationOneCDx. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained before the service was rendered. 
 
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 targeted genomic sequence analysis (0037U) provided on 
June 22, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service April 20, 
2022. 
 
  You asked the Plan to pay for procedure code 74018. You say that procedure code 74018 was not bundled with 
any other procedure code performed on the same date of service.  You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says payment for 
code 74018 is bundled into payment for code 74240. 
 
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 74018 
is a column II code to column I code 74240. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 74018 billed for date of service April 20, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing provided on March 14, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the testing 
is not covered by Medicare. 
 
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. 
 
We looked at the file and the rules. This testing was provided to the enrollee who has a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. The Plan hasnt proven their argument 
that the DOS is incorrect based on the fact that the sample at issue may meet one of the exceptions The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the laboratory testing provided on March 
14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 documentation shows that you have functional impairments. However, from 
a medical standpoint, you are stable on an outpatient basis and there is no documentation to show that you 
require an acute inpatient hospital stay. Additionally, there is no clear documented rehabilitation diagnosis 
(etiology) related to documented functional impairments thus no clear indication that you would make 
significant functional gains. 
 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve the wireless capsule endoscopy. You say that there is no indication the 
enrollee requires a repeat colonoscopy. You also say that the capsule endoscopy should be approved. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopies are indicated for 
investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure 
gastrointestinal (GI) bleeding who have had upper and lower GI endoscopies within the past 12 months. 
 
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 wireless capsule endoscopy. Our 
reviewer says that a wireless capsule endoscopy is not medically necessary. Our physician reviewer found 
since the last colonoscopy dates to March 31, 2021, it as such does not meet the above criteria for a negative 
colonoscopy exam within 12 months of the requested service. Therefore, the reviewer found that the requested 
service 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 the wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate procedure (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says 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 the bone marrow aspirate procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service 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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone marrow aspirate procedure (20939).