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

 
We decided that the Plan does not have to pay for the lab services provided on September 13, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the medical records 
submitted do not include a physician order or laboratory requisition for the billed test. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on September 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73501 billed for date of service September 
23, 2022. 
 
You asked the Plan to pay for procedure code 73501. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 73501 is bundled into payment for 
code 73502. 
 
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 73501 is a column II code to column I code 73502. The  code at issue 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
73501 billed for date of service September 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (87651, 87481, 87641) provided on July 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that they were unable to review the appeal within the allowed time frame. 
 
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. The plan denied the services at issue stating medical records were not submitted. 
The records include lab results and the lab order for this service. Therefore, we decided that the Plan has to pay 
for lab services (87651, 87481, 87641) provided on July 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is chronically deconditioned due to multiple chronic illnesses with an 
acute decline due to over-treatment of his kidney disease. The enrollee does not require intensive rehabilitation 
services and does not require frequent physiatry oversight. the enrollee's condition is stable, and the enrollee 
requires standard post-acute rehabilitation as is done without an IRF admission. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an office visit with an out-
of-network provider. 
 
You asked the Plan to pre-approve the network exception. You say that you have had complications from 
cataract surgery that three different doctors at two different practices have not been able to correct. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the network exception have not been met. Therefore, we decided that the Plan does not have to pre-
approve an in-network exception for an office visit with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
left total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. 
The Plan says there is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is scheduled/approved for a left total shoulder arthroplasty. 
The record does not document that the treating physician has a reasonable expectation of a length of stay 
spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 6, 2021, billed with 
multiple codes including 81439, 81286, 81404, 81405, 81406 and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 6, 2021, billed with multiple codes including 81439, 81286, 81404, 81405, 81406 and 81407.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a cellphone 
holder and a cup holder (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you need the cup and cellphone holder 
because you are limited to one hand. You would like the elevated seat due to needing to be on eyelevel with 
your peers and to get things around your home done on your own. The Plan denied your request. The Plan says 
the requested accessories are not covered by Medicare or your Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
We looked at the file and Medicare rules. Medicare rules say a power seat elevation feature is non-covered 
because it is not primarily medical in nature. The seat can be set at a height to meet your activities of daily 
living. The requested cellphone holder and cup holder do not serve a purpose that is primarily medical in 
nature. Based on this information, we decided that Medicare rules for coverage of wheelchair accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system 
(E2300), an electronic connection between wheelchair controller and two or more power seating system motors 
(E2311), a cellphone holder and a cup holder (K0108).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to care for yourself at home, and 
your stairs are a fall risk. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. Your care needs, custodial and 
intermittent, can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the specialty occupational multifocal lenses (V2786). 
 
You asked the Plan to pre-approve specialty occupational multifocal lenses. You say that due to health 
conditions you need this lens, and not the one that was approved because you cannot wear glasses. The Plan 
denied your request. The Plan says that the requested lens is not covered by Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $700 every year for all additional eyewear. 
 
We looked at the file and the Plan's rules. The contract clearly states that the Plan covers eyeglass lenses, and 
no exclusions are specified. Based on this information, we decided that the Plan's rules for coverage of 
specialty occupational multifocal lenses have been met. Therefore, we decided that the Plan has to pre-approve 
the specialty occupational multifocal lenses (V2786).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is at high risk for fracture. The Plan denied 
your request. The Plan says the requested drug is not FDA approved for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Prolia. Our reviewer says that the 
requested drug, Prolia, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not medically reasonable 
or necessary 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic 
obstructive pulmonary disease (COPD) and interstitial lung disease. Pulmonary function tests consist of 
spirometry, but no flow volume loop is provided. Spirometry is consistent with severe restrictive lung disease. 
There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) retention. 
Thus, criteria are not met for ventilatory support during sleep. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) during sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thoracic aortography and carotid, vertebral, and 
subclavian angiography to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient procedure. You say that you disagree with the denial and are 
requesting reconsideration for the denied service. The Plan denied your request. The Plan says the records 
received do not indicate that the enrollee has an emergent or urgent medical condition or needs a specialized 
service(s) that are not available in the network. The enrollee has an HMO (Health Maintenance Organization) 
plan. There are in-network provider(s) within a reasonable distance from her location that can provide this 
service or item. 
 
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 
a thoracic aortography and carotid, vertebral, and subclavian angiography to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system (E1007), a manual swingaway 
(E1028x2), 22nf sealed lead acid battery (E2361x2), an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a 
skin protection and positioning wheelchair seat cushion (E2607), a positioning wheelchair back cushion 
(E2620), a headrest (E0955), an addition to power seating system (E1012), and an adjustable angle footplate 
(K0040). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair accessories 
are medically necessary. The Plan denied your request. The Plan says the requested additional power features 
are not medically necessary at this time as you have no history of pressure ulcers, you are able to perform 
weight-shifting independently and are able to transfer with supervision to your bed for leg swelling 
management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you do not meet criteria for approval of the 
requested power features and wheelchair accessories. The records show that you have no history of pressure 
ulcers, and you can complete MRADLs independently. Based on this information, we decided that Medicare 
rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seating system (E1007), a manual swingaway (E1028x2), 22nf sealed lead acid 
battery (E2361x2), an electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), a harness (E2313), an expandable controller (E2377), a skin protection and positioning 
wheelchair seat cushion (E2607), a positioning wheelchair back cushion (E2620), a headrest (E0955), an 
addition to power seating system (E1012), and an adjustable angle footplate (K0040).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection for COVID-19 billed with 
codes U0003 and U0005 for August 16, 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 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee underwent COVID-19 
testing. There is no documentation indicating the clinical rationale for the testing. The records do not support 
that the criteria for coverage of infectious agent detection are met. The testing was therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the infectious agent detection for COVID-19 billed with codes U0003 and U0005 for August 
16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia tablets. 
 
You asked the Plan to pre-approve Kerendia tablets. You say that the enrollee has been on Kerendia since July 
2019, and has been stable for chronic kidney disease. The Plan denied your request. The Plan says Kerendia is 
a self-administered drug, and does not fall under Part B coverage. 
 
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 Kerendia tablets.  
 
Benefits for Kerendia tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 injections. Our reviewer says that 
the requested facet joint injections are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee achieved 80% pain relief from the previous injections. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494, 64495).