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

 
We decided that the Plan has to pay for the DecisionDx-Melanoma test provided on August 11, 2022. 
 
You asked the Plan to pay for the DecisionDx-Melanoma test. You say that this is an approved test that was 
ordered by the enrollee's treating physician to inform treatment decisions. The Plan denied your request. The 
Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, no medical records were included with the case file for review.  
Therefore, we decided that the Plan has to pay for the DecisionDx-Melanoma test provided on August 11, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression 
(PILD)/Minimally Invasive Lumbar Decompression procedure (MILD) procedure. 
 
You asked the Plan to pre-approve the PILD/MILD procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar Decompression 
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 the PILD/MILD procedure. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there are no 
objective exams provided. The last exam provided from February 2, 2023, noted that she was doing well and 
was to follow-up as needed. Detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. Moreover, the documentation does not 
corroborate that this enrollee is enrolled in a study. Therefore, the enrollee does not meet the coverage criteria 
detailed in the NCD. 
 
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 PILD/MILD procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Percutaneous Image-Guided Lumbar Decompression (PILD)/Minimally 
Invasive Lumbar Decompression procedure (MILD) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that this item is medically necessary. The 
Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as non-
covered, since it does not meet the definition of a prosthesis. 
 
We looked at the file and Medicare rules. This item is not eligible for coverage. Based on this information, we 
decided that Medicare rules for coverage of a mastectomy sleeve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inflatable, donut cushion/pillow/wedge (E0190). 
 
You asked the Plan to pre-approve a donut cushion. You say that you are appealing the denial of an inflatable 
donut for your wheelchair. You need the donut because everything you sit on causes you pain. The Plan denied 
your request. The Plan says this item is considered a convenience item and is not covered. 
 
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 pre-approve an inflatable, donut cushion/pillow/wedge (E0190).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed.. You say that you have provided medical 
records to support this request. The Plan denied your request. The Plan says total electric hospital beds are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computerized dynamic posturography (code 92549). 
 
You asked the Plan to pre-approve computerized dynamic posturography. You say that computerized dynamic 
posturography is medically necessary. The Plan denied your request. The Plan says computerized dynamic 
posturography is 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 computerized dynamic posturography. 
Our reviewer says that the requested computerized dynamic posturography is not considered medically 
reasonable and necessary. Our physician reviewer found that based on the medical records provided and review 
of the current peer-reviewed medical literature there is inadequate support to show that the computerized 
dynamic posturography at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The provided medical records and review of the current peer-reviewed medical literature do 
not document that use of the computerized dynamic posturography has been shown in controlled studies to 
result in long term health benefits in patients with dizziness and giddiness.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computerized dynamic posturography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computerized dynamic posturography (code 92549).
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 enrollee needs inpatient rehabilitation to regain 
maximum function, rehabilitation needs and close physician supervision. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pay for the pneumatic compression device provided on September 
20, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88304, 88307, & 88311 billed for date of 
service October 9, 2022. 
 You asked the Plan to pay for procedure code(s) 88304, 88307, & 88311. You say that these services were 
medically necessary. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88304, 88307, & 
88311. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88304, 
88307, & 88311. Based on this information, we decided that Medicare rules for coverage of procedure code 
88304, 88307, & 88311 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88304, 88307, & 88311 billed for date of service October 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty. 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in enrollees who meet specific criteria. 
 
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 vertebroplasty/kyphoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the imaging studies 
do not show an acute fracture that is less than 6 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty/kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertebroplasty/kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacroiliac joint injection, anesthetic/steroid, with 
image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
 
You asked the Plan to pre-approve the injection procedure. You say that the medical records were submitted to 
support that the enrollee underwent physical therapy and occupational therapy and also medications as well. 
The Plan denied your request. The Plan says based on Medicare guidelines, the sacroiliac joint (SIJ) injection 
requested does not meet the requirements for approval 
 
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 injection procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has tried rest, behavior modification, ice/heat and has had one session of 
Physical therapy. The physical exam notes tenderness but does not detail 3 provocative maneuvers that 
Medicare requires. Medicare guidance requires documentation of physical examination with at least 3 positive 
provocative tests of sacroiliac pain. Therefore, the request is deemed not medically 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 the injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sacroiliac joint injection, anesthetic/steroid, with image guidance (fluoroscopy 
or CT) including arthrography when performed (27096).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment therapy provided no November 21, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that 
individual providers cannot bill code G2067. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The information provided in the case file shows that the billing provider is a valid OTP provider. The Plan has 
not shown that the billing provider is not enrolled as an entity enrolled with Medicare as an OTP. Based on this 
information, we decided that Medicare rules for coverage of the services provided have been met. Therefore, 
we decided that the Plan has to pay for the opioid treatment therapy provided no November 21, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy for lymphedema to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy for lymphedema to be provided by an out-of-network 
provider. You say that there is no availability with an in-Plan provider for this therapy. The Plan denied your 
request. The Plan says the care is available in-Plan and by a Plan specialist. Additionally, the member is 
contractually required obtain covered services from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy for lymphedema to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel (80053) and complete 
blood count (CBC) (85025) provided on April 8, 2021, to April 13, 2021. 
 
You asked the Plan to pay for the comprehensive metabolic panel and CBC. You say that this claim should be 
processed. The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 comprehensive metabolic panel and CBC was not filed until April 19, 
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 comprehensive metabolic panel (80053) 
and complete blood count (CBC) (85025) provided on April 8, 2021, to April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the enrollee needs this device. 
The Plan denied your request. The Plan says this device is not covered because the enrollee is not on insulin. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic medication dispenser (E1399). 
 
You asked the Plan to pre-approve an automatic medication dispenser. You say that you have difficulty with 
your medications. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
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 pre-approve an automatic medication dispenser (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cochlear device implantation, with or without 
mastoidectomy (69930) and cochlear device, includes all internal and external components (L8614). 
 
You asked the Plan to pre-approve the cochlear implantation. You say that you requested prior approval for 
Cochlear Implant surgery back on 08/03/22 and the request was approved. The enrollee had to put the surgery 
on hold, and you have submitted a new prior authorization and was denied. The Plan denied your request. The 
Plan says the cochlear implantation requested does not meet the requirements for approval. 
 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 cochlear implantation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the cochlear implant at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee. The provided records in this case do 
not document the enrollee has bilateral moderate-to-profound sensorineural hearing loss with test scores of less 
than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence 
recognition, as required by the National Coverage Determination (NCD) Cochlear Implantation 50.3. The 
records document mild to severe left-sided hearing loss and a test score of 68% correct in the best-aided 
listening condition. 
 
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 cochlear implantation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the cochlear device implantation, with or without mastoidectomy (69930) 
and cochlear device, includes all internal and external components (L8614).