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

 
We decided that the Plan does not have to pre-approve a Pride Revo 2.0-3-Wheel scooter (K0899). 
 
You asked the Plan to pre-approve a Revo scooter. You say that the scooter is medically necessary. The Plan 
denied your request. The Plan says that the specific brand name scooter is not medically necessary. 
 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 a Revo scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the Revo scooter has advanced 
features and is not a basic scooter. Medicare authorizes a basic scooter for home use. The requested scooter 
exceeds the enrollee's 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 a Revo scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Pride Revo 2.0-3-Wheel scooter (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2042 billed for date of service September 1, 
2022, to September 30, 2022. 
 
You asked the Plan to pay for procedure code T2042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code T2042 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2042 billed for date of service September 1, 2022, to September 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services billed with codes 97129 and 
92507 for November 2, 2022, to November 30, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must be billed with the 
GN, GO, or GP modifier.  
 We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
GN, GO, or GP modifiers. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient therapy 
services billed with codes 97129 and 92507 for November 2, 2022, to November 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show radicular symptoms and neurogenic claudication. An Intracept 
procedure is not medically appropriate. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on September 20, 
2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted this benefit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on 
September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable gaseous oxygen system, rental; includes 
portable container, regulator, flowmeter, humidifier, cannula or mask, (E0431). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that you are out of oxygen tanks. You have 
pneumonia and it is very had to breath. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 oxygen equipment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a portable oxygen system is not medically necessary. This enrollee has chronic 
obstructive pulmonary disease and asthma overlap syndrome. A 6-minute walk test breathing room air on 
March 1, 2023, showed that the lowest SPO2 was 95%. This does not meet Medicare criteria for oxygen need. 
 
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 oxygen equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable gaseous oxygen system, rental; includes portable container, regulator, 
flowmeter, humidifier, cannula or mask, (E0431).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical 
First Assistant (CSFA) on April 11, 2022. 
 
You asked the Plan to pay for the CSFA services. You say that the surgeon and facility are in-network, so the 
surgical assistant services should be covered. The Plan denied your request. The Plan says a CSFA is not a 
valid provider type for billing Medicare for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Certified Surgical First Assistant (CSFA) on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug does not meet step therapy criteria.  
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the case file does 
not contain documentation of trial and failure of Orthovisc, Mononvisc, Synvisc and or Synvisc-one. The 
documentation does not support that Orthovisc, Mononvisc, Synvisc and or Synvisc-one 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
August 16, 2022. 
 
You asked the Plan to pay for the drug testing services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable. Codes 
80307 and G0480 are not supported with the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. Medicare rules also 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. In addition, we found that codes G0480 and 80307 are not supported by the records 
provided. The physician order does not specify which drug classes are requested for testing, and there are no 
physician notes from the ordering provider to indicate which classes are requested and considered medically 
necessary in this case. The laboratory results also do not include the results of any presumptive testing to 
support that code 80307 was performed. Based on this information, we decided that the rules for coverage of 
codes G0480 and 80307 also have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0480, 80307 and 83789) provided on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. You say that the requested hospital bed is medically 
necessary. The Plan denied your request. The Plan says the requested hospital bed is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the requested hospital bed is not medically necessary. Our physician reviewer found the enrollee's physician 
asserts the enrollee requires head of bed to be elevated above 30 degrees, but states chronic conditions are 
stable and provides no specific indication for elevation such as orthopnea or nocturnal dyspnea or evidence the 
current bed is inadequate.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF setting is the most appropriate to reach the 
enrollee's desired outcomes. The Plan denied your request. The Plan says the requested 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 clinical documentation does not specify any complex functional impairments or 
active medical comorbidities. Thus, the complexity of the enrollee's documented nursing, medical, and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. Clinical documentation shows the enrollee has participated with physical 
therapy and occupational therapy with functional impairments, but there is no documentation to support the 
enrollee requires an intensive rehabilitation regimen.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a XEN device (0449T). 
 
You asked the Plan to pre-approve a XEN device. 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 a XEN45 device 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 a XEN device. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee does not have refractory 
glaucoma with intraocular pressure over 20mmHg on maximally tolerated medical therapy (4 classes of topical 
IOP-lowering medications). The enrollee does not meet coverage criteria detailed in the LCD. 
 
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 XEN device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a XEN device (0449T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
tertiary level of care provider. 
 
You asked the Plan to pre-approve a continuation of care with an OON tertiary level of care provider. You say 
that the OON provider you have been seeing is the reason your mantle cell is stable and managed at this time. 
You say that you need to see the requested provider for restaging and continued management. You say that you 
were told you could stay with this doctor when you changed insurance providers. The Plan denied your request. 
The Plan says the enrollee's clinical records do not meet the criteria for a high level of care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
tertiary level of care provider. Our reviewer says that the criteria for coverage of OON care have not been met. 
Our physician reviewer found the tertiary level of care is not medically reasonable and necessary. There is 
nothing unique about your condition that would make it medically necessary to continue care with the OON 
provider. The Plan has shown that they have in-network specialists who have the qualifications and expertise to 
meet the current medical Standards of Care required for treatment of your condition. Your medical 
management and follow-up care can be safely transitioned to an in-network specialist at this time. 
 
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 continuation of care with an OON tertiary level of care provider have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out-of-
network (OON) tertiary level of care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0857) and 
additional wheelchair options/accessories (codes E1002, E1012, E1028, E2310, and E2361). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional wheelchair 
options/accessories. You say that you feel the denial was incorrect since the enrollee does meet medical 
necessity based on Medicare guidelines for the tilt seating system. The Plan denied your request. The Plan says 
the enrollee does not have a qualifying diagnosis causing mobility limitation for which a group 3 power 
wheelchair is medically needed. The Plan also says as the enrollee does not qualify for the wheelchair base, 
none of the requested accessories can 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 a group 3 standard power wheelchair 
and additional wheelchair options/accessories. Our reviewer says that the enrollee does not meet the coverage 
criteria for a group 3 standard power wheelchair and additional wheelchair options/accessories. Our physician 
reviewer found it is not clear that the enrollee, with dementia, is able to safely manage a power wheelchair; 
secondly, no high risk for skin breakdown; third, no spasticity and no catheter use. Our reviewer also found the 
enrollee does not require power tilt or tilt and recline and does not require the chair because of neuromuscular 
disease or congenital spine disease. 
 
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 group 3 standard power wheelchair and additional wheelchair 
options/accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair (K0857) and additional wheelchair options/accessories (codes E1002, 
E1012, E1028, E2310, and E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy services provided on November 11, 2022, 
billed with code 31622-59. 
 
You asked the Plan to pay for the services as billed. You say that this should be covered as the service was 
medically necessary. The Plan denied your request. The Plan says a "scout" endoscopy to assess anatomic 
landmarks or assess extent of disease preceding another surgical procedure at the same encounter is not 
separately reportable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 31622 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure). 
 
We asked our coder 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 the services as billed. Our reviewer says that the medical 
records do not support the billed code or the use of modifier -59. Our reviewer found this service was billed in 
addition to a surgical thoracoscopy with total pulmonary decortication. The use of modifier -59 cannot be 
verified in operative report, as operative report does not include enough documentation to support medical 
necessity for the separate and distinct bronchoscopy prior to the primary procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the bronchoscopy services provided on November 11, 2022, billed with code 31622-
59.