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

 
We decided that the Plan does not have to pre-approve the CGM receiver (CPT code K0554). 
 
You asked the Plan to pre-approve the CGM receiver. You say that the receiver 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 did not show the enrollee tests their sugar four or 
more times a day. There were also no notes that the enrollee gets insulin three or more times a day and there are 
no notes that the enrollee needs to have their insulin adjusted a lot. Based on this information, we decided that Medicare rules for coverage of the CGM receiver have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the CGM receiver (CPT code K0554).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occupational therapy services to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network occupational therapy services. You say that the services 
are necessary. The Plan denied your request. The Plan says the requested provider is not 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the 
occupational therapy services 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 a pathologist tissue exam (88305) and a decalcification of 
tissue procedure (88311) provided on December 22, 2021. 
 
You asked the Plan to pay for a pathologist tissue exam and a decalcification of tissue procedure. You say that 
the services at issue were billed correctly. 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 the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pathologist tissue exam and a decalcification of tissue procedure have not been met. Specifically, 
this claim was billed with the outpatient POS code. The case record does not support that services were 
provided in an outpatient setting. Therefore, we decided that the Plan does not have to pay for a pathologist 
tissue exam (88305) and a decalcification of tissue procedure (88311) provided on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of bilateral L3-L4 and 
L4-L5. 
 
You asked the Plan to pre-approve RFA. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is only covered for certain indications. 
 
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 RFA. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain. The enrollee takes Tramadol for pain. The 
enrollee has done a home exercise program. She had two sets of diagnostic medical branch blocks where the 
first gave 50% pain relief and the second 80%. This does not meet the criteria of both blocks producing 80% 
pain relief. Therefore, the enrollee does not meet criteria for the requested 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of bilateral L3-L4 and L4-L5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you are overweight, and the scooter will 
balance out your weight to decrease bodily stress. The Plan denied your request. The Plan says a knee scooter 
does not meet the program's requirements for Medicare coverage. 
 
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 a crutch substitute, lower leg platform, with or without 
wheels (E0118).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility services. 
 
You asked the Plan to pre-approve the additional skilled nursing facility services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the skilled nursing facility benefit has been 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 20, 2022 to 
July 29, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional skilled nursing facility services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from February 2, 2021, through 
February 4, 2021, at DRG 682. 
 
  You asked the Plan to pay for inpatient services at DRG 682. You say that the assignment of a diagnosis code 
is based on the provider's diagnostic statement that the condition exists. You say that documentation of acute 
renal failure was present in the progress notes and payment should be approved at the originally billed DRG. 
The Plan denied your request. The Plan says the clinical documentation does not support the diagnosis code 
N17.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code N17.9, defined as acute renal failure, 
unspecified. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for inpatient services at DRG 682. Our 
reviewer says that the documentation does not support diagnosis code N17.9. Our physician reviewer found the 
enrollee was evaluated and admitted with a diagnosis of hypernatremia, hypomagnesemia, hypocalcemia, 
urinary tract infection and malnutrition. There was no documentation of acute renal failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from February 2, 2021, through February 4, 2021, at DRG 682.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve female external urinary collection device (CPT code 
A4328). 
 
You asked the Plan to pre-approve the device. You say that you do not get the sores and infections using the 
Purewick system. When there is no control over urinary system you get diapers which cause sores and 
infections and cannot tell when you go. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 female external urinary collection device (CPT code 
A4328).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481.  
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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service February 1, 2022.
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 [Enter appellant's argument from appeal letter, e.g. 
"...you need SNF care."] The Plan denied your request. The Plan says the continued IRF services are 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 complexity of the patients nursing medical, and rehabilitation needs no longer 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
continued to require treatment by multiple therapies, including physical therapy, occupational therapy, and 
occupational therapy. Our reviewer found that as of June 13, 2022, the patients mobility and function with 
regards to activities of daily living plateaued. He continued to require minimal assistance with transfers and 
mobility with a walker and moderate assistance with most activities of daily living. Our physician reviewer also 
found that while he required continued therapy, his progress had slowed, and he did not require the intensity of 
therapies provided in the acute inpatient rehabilitation, especially given that he was to be discharged to a 
skilled nursing facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis (Q5104). 
 
You asked the Plan to pre-approve Renflexis. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Renflexis. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis. Our reviewer says that 
Renflexis is not reasonable and necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of two of the preferred step therapy drugs including Remicade, infliximab, 
Inflectra, Simponi Aria, and Stelara. Our reviewer also found that the documentation does not support that the 
Plan's required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis (Q5104).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on February 18, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that the service is coded correctly with the appropriate 
modifier. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 The file shows that the enrollee was under incarceration at the time the services were provided. We find that 
CPT code 71045 was not billed with a modifier suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does 
not have to pay for the chest x-ray provided on February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan Hycela. 
 
You asked the Plan to pre-approve Rituxan Hycela. You say that you would like the enrollee to be approved to 
get subcutaneous Rituximab. The Plan denied your request. The Plan says the patient must first tolerate 
intravenous Rituximab, there should be less risk if IV Rituximab (given as Ruxience) is continued if tolerated. 
The Plan also says if IV Rituximab is not tolerated, then Rituxan Hycela should not be used. 
 
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 Rituxan Hycela. Our reviewer says that 
Rituxan Hycela is not reasonable and necessary. Our physician reviewer found Rituxan Hycela is Food and 
Drug Administration (FDA) approved and supported by the major drug compendia for the treatment of B-cell 
lymphoma, but only following a full dose of a Rituximab product (375 mg/m(2)) by intravenous (IV) infusion. 
Our reviewer found that Rituxan Hycela is indicated, supported and recommended, and is safe and effective 
and otherwise reasonable and necessary for the treatment of B-cell lymphoma but only following a full dose of 
a Rituximab product (375 mg/m(2)) by IV infusion. Our physician reviewer also found that the records do not 
document a recent full dose of a Rituximab product (375 mg/m(2)) by IV infusion has been administered and 
tolerated in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan Hycela have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituxan Hycela.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) purchased March 2, 2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you needed the device and purchased it 
from the only available vendor. The Plan denied your request. The Plan says if you go to a provider who is not 
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) 
purchased March 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole. 
 
You asked the Plan to pre-approve Pantoprazole. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Pantoprazole is not covered under the enrollee's Medicare 
Part B benefit. 
 
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 Pantoprazole.  
 
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker with seat attachment. 
 
You asked the Plan to pre-approve the DME. You say that you never received a walker with a seat. The Plan 
denied your request. The Plan says you report that you did receive a walker within the past 5 years. The Plan 
states there is no other documentation to show a decline where you would need the seat attachment. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that you 
received a rollator walker in September of 2021, less than 5 years ago. Therefore, we decided that the Plan does 
not have to pre-approve a rollator walker with seat attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on February 21, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that post-surgical services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99232 (subsequent hospital care) 
was billed within the 90 day surgical period of major procedure 28805 (foot amputation) on December 23, 
2021. Payment for these services is included in the global surgical package. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care rendered on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 24, 2021. 
 
You asked the Plan to pay for the services provided. You say that the treatment sought was a covered service. 
The Plan denied your request. The Plan says the screening panel was initiated by the lab. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that a hereditary genetic cardiac test was provided. It appears this testing may have been ordered 
by an unsolicited outreach telephone call to the enrollee. The records also show that the services were 
requested solely for screening purposes. Screening services such as pre-symptomatic genetic tests used to 
detect an undiagnosed disease are not a Medicare benefit and are not covered. Therefore, we decided that the 
Plan does not have to pay for the lab testing services provided on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for a tub or toilet (E0247). 
 
You asked the Plan to pre-approve a bathtub transfer bench. You say that you have weak bones, and your legs 
are swollen. You have difficulty in the shower, and you cannot stand for long. You say you desperately need 
this bench, so you do not fall and get hurt. The Plan denied your request. The Plan says the requested item is 
not a covered item with your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a transfer bench for a tub or toilet are not covered 
because they are not primarily medical in nature.  
 
While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench for a tub or toilet 
(E0247).