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

 
We decided that the Plan does not have to pre-approve the Freestyle Libre CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is necessary. The Plan denied 
your request. The Plan says the Medicare rules 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 does not indicate that the enrollee is insulin-
treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin 
infusion (CSII) pump; and that the enrollee's insulin treatment regimen requires frequent adjustment by the 
enrollee on the basis of blood glucose monitor or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Freestyle Libre CGM and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve these services. You say that you need this for your health. The Plan denied 
your request. The Plan says that this device has deluxe features that exceed your need and replaces, rather than 
improves the function of your arm. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. At this time the 
requested robotic orthosis is not proven to be more beneficial for treatment of your medical condition/function 
of hemiparesis after stroke than any available standard therapy. 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 patient, 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. 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 the MyoPro Motion G Orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, ischial 
containment/narrow M-L socket (L5649), an addition, endoskeletal system, below knee (BK), flexible 
protective outer surface covering system (L5962) and an all-lower extremity prosthesis, shank foot system with 
vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve prosthetics. You say that all parts have been approved but 2. You need a 
foot system to walk. You are a function K3-K4 level for ambulation and walks everywhere. The Plan denied 
your request. The Plan says you do not meet criteria for the requested prosthetics. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a below knee amputation. The requested ischial containment socket is for an above 
the knee amputation. The advanced foot system exceeds your needs. The documentation does not include 
treating medical physician progress notes with details of your functional level and activities to support 
indications for this advanced foot feature. The flexible protective outer surface covering system exceeds your 
medical needs and is not medically necessary per Medicare criteria as the documentation does not support that 
you require this protection against unusually harsh environmental situations where it is necessary to protect the 
lower limb prosthesis beyond the level of protection that is afforded by a standard cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower extremity, ischial containment/narrow M-L socket (L5649), an 
addition, endoskeletal system, below knee (BK), flexible protective outer surface covering system (L5962) and 
an all-lower extremity prosthesis, shank foot system with vertical loading pylon (L5987).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and 
the requested accessories/items. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the notes do not show that the enrollee needs both of the power options, and the 
upgraded controller, harness and electronics cannot be covered as there is not a medical need to control more 
than two power options through the joystick. The Plan states these cannot be covered, and the seat lift does not 
serve a medical purpose and cannot be covered. The Plan states the pelvic/thigh guide is a duplicate service 
with requested thigh supports; these cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 DME. Our physician reviewer 
found there is no documentation that the group 3 power wheelchair with multiple power option (power tilt, 
power recline and power seat elevation) at issue in this case meets Medicare criteria for medically reasonable 
and necessary. The requested power seat elevation feature is statutorily non-covered as it serves no primary 
medical purpose. Records do not document the patient performs "intermittent" bladder catheterization or that 
the patient has increased muscle tone or spasticity to meet LCD: Wheelchair Options/Accessories (L33792) 
criteria for the power recline feature. The enrollee appears to meet criteria for a group 3 power wheelchair with 
a single power option. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (CPT code K0861) and the requested accessories/items.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Emergency Department visit provided on May 3, 2022. 
 
You asked the Plan to pay for the Emergency Department visit. You say that you disagree with the Plan's 
denial. 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 May 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 the Emergency Department visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the Emergency Department visit 
provided on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hypercoagulability genetic testing (CPT code(s): 
81241 and 81240). 
 
You asked the Plan to pre-approve the testing. You say that the testing is medically necessary. The Plan denied 
your request. The Plan says the enrollee's request is not medically necessary because their records show the 
enrollee's provider does not plan to alter the enrollee's current management plan as a result of these genetic 
tests. 
 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 testing. Our physician reviewer 
found the provider does not plan to alter their current management plan as a result of these genetic tests. The 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the hypercoagulability genetic testing (CPT code(s): 81241 and 81240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexabed (E1399). 
 
You asked the Plan to pre-approve a Flexabed. You say that you need this bed due to medical reasons, which 
include split discs, herniated disc, asthma, chronic bronchitis, sleep apnea as well as other issues. The Plan 
denied your request. The Plan says they do not have evidence that the Flexabed is 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 Flexabed. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested prosthesis is not medically necessary for the diagnosis or treatment of illness, 
injury, or to improve the functioning of a malformed body member. The documentation does not reveal 
extenuating factors that require this brand bed over a standard hospital bed. 
 
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 Flexabed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Flexabed (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avonex pre-filled kit 30 mcg. 
 
You asked the Plan to pre-approve Avonex. You say that the enrollee has been stable on this drug for years. 
The Plan denied your request. The Plan says Avonex is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Avonex pre-filled kit 30 
mcg.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) billed for date of service March 14, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the genetic testing was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the 
genetic testing was billed with the incorrect date of service. 
 
The Plan must follow Medicare rules. The rules say that, with certain exceptions as detailed in the Medicare 
rules section of this letter, the DOS of the test/service must be the date the specimen was collected. The rules 
also say that plans must make reasonable and diligent efforts to gather and forward information to the IRE. 
 
We looked at the file and Medicare rules. In this case, the case record indicates that the billed DOS must be the 
date the test was performed because the criteria for an exception to the rules is met. The Plan has not indicated 
that the specimen was collected during an inpatient encounter. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the denial has not been substantiated. Based on this information, we decided 
that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (0037U) billed for date of service 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing servies provided on April 15, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the drug testing servies provided on April 15, 2022 by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on January 4, 2022. 
 
You asked the Plan to pay for the services provided. You say that no other code exists for the removal of the 
central compartment nodes. The Plan denied your request. The Plan says the code is inclusive to another code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 38999 is unlisted procedure, hemic or lymphatic system. 
We find that CPT code 38999 is not supported in the medical record. Specifically, the record does not show 
that multiple procedures were performed in the same session. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgery services provided on January 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the residential treatment services received March 14, 2022, to April 8, 
2022. 
 
You asked the Plan to pay for the residential treatment services. You say that you feel these services received 
were medically necessary. The Plan denied your request. The Plan says that the services received are not a 
covered benefit. 
 
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. Review of the file shows that the Plan submitted this case without a clear 
Medicare rule to state that residential treatment services are specifically not covered. The Plan states that 
according to the 2022 Evidence of Coverage (EOC) this service is specifically not covered. However, that is 
not correct. The EOC does not specifically state that these services are not a covered benefit. This means that 
the Plan did not follow Medicare rules for disclosure of coverage and cost sharing information. Therefore, the 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the residential 
treatment services received March 14, 2022, to April 8, 2022 minus any cost share requirement.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87641, 87798, 88305 and 88312) billed 
for date of service May 10, 2021. You asked the Plan to pay for laboratory services. You say that these services are supported in the medical 
records and should be paid. The Plan denied your request. The Plan says the submitted documentation does not 
contain a signed physician order or authenticated medical records from the ordering provider documenting that 
the treating physician had intended for this testing to be performed. Without this information, medical necessity 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also state that all diagnostic laboratory tests must be ordered by the 
physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a 
beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's 
specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable 
and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no physicians order was provided with evidence that this testing was requested by a provider who 
is currently treating the enrollee. In addition, no medical records or progress note were provided to support the 
medical necessity and intent to perform this testing. Therefore, we decided that the Plan does not have to pay 
for laboratory services (87641, 87798, 88305 and 88312) billed for date of service May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0481, 80307) provided on May 7, 
2021. 
 
You asked the Plan to pay for drug testing services. You say that you did not receive the enrollee's correct 
insurance information from the referring provider. The Plan denied your request. The Plan says this claim was 
filed after the timely filing limit and therefore is denied. 
 
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 drug testing services was not filed until May 12, 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 drug testing services (G0481, 80307) provided on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 22, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 22, 2022.