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

 
We decided that the Plan does not have to pre-approve a preset portable oxygen system with rechargeable 
batteries (E1399). 
 
You asked the Plan to pre-approve a preset portable oxygen system with rechargeable batteries. You say that 
your quality of life has been severely affected. You broke your arm and cannot walk around with an oxygen 
tank. You cannot go anywhere without bringing two oxygen tanks. You get very shaky and cannot function 
because your oxygen levels get too low. The Plan denied your request. The Plan says per Medicare guidelines, 
a preset portable oxygen system is specifically excluded from coverage as they are precautionary equipment, 
and essentially not therapeutic in nature. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a preset portable oxygen system with rechargeable batteries have not been met. Specifically, a 
preset portable oxygen system is excluded from coverage as they are essentially not therapeutic in nature. 
Therefore, we decided that the Plan does not have to pre-approve a preset portable oxygen system with 
rechargeable batteries (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM supply allowance provided on March 25, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says they have received 
confirmation from the ordering provider's office that they did not write the order for the Continuous Glucose 
Monitor. 
 
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 only medical record provided is from June 22, 2021. The 
requested monthly supply was delivered in March 2022. Since there is no evidence that that enrollee had a visit 
with the treating provider within six months of this delivery, it cannot be confirmed that the enrollee continues 
to meet the coverage criteria. Based on this information, we decided that Medicare rules for coverage of the 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the CGM supply 
allowance provided on March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77001 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 77001. The Plan denied your request. The Plan says payment for 
code 77001 is bundled into payment for code 32651.  
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 77001 
is a column II code to column I code 32651. This claim 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 77001 billed for date of service April 5, 2022.
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 have been in the hospital multiple times since 
surgery and home health did not help. You say that you are weak, and you should be fine in 5 days with SNF 
care. The Plan denied your request. The Plan says the SNF admission 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 your functional status is able to improve at a home care level with repetitive exercise 
and support from non-skilled persons. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim 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 70450 billed for date of service April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve the lightweight wheelchair. You say that the wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a wheelchair is covered when the beneficiarys 
mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker and the 
beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for use of the 
manual wheelchair that is provided. 
 
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 lightweight wheelchair. Our 
reviewer says that the requested wheelchair is not medically necessary. Our physician reviewer found the 
documentation doesn't support that the enrollee requires a wheelchair in the home for mobility-related activities 
of daily living or that a wheelchair can be maneuvered in the home. The documentation indicates the enrollee is 
ambulating with a walker. 
 
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 lightweight wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 29, 
2022. 
 
You asked the Plan to pay for procedure code 99072. The Plan denied your request. The Plan says procedure 
code 99072 is considered bundled and not separately payable. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 93042 billed for date of service 
March 25, 2022. 
 
You asked the Plan to pay for procedure codes 93010 and 93042. The Plan denied your request. The Plan says 
payment for codes 93010 and 93042 is bundled. 
 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 93010 
is a column II code to column I code 36556, and that code 93042 is a column II code to column I code 99291. 
This claim 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 codes 93010 and 93042 billed for date of service March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins and injection of 
sclerosant of multiple incompetent veins. 
 
You asked the Plan to pre-approve Stab phlebectomy of varicose veins and injection of sclerosant of multiple 
incompetent veins. You say that the requested Stab phlebectomy of varicose veins and injection of sclerosant of 
multiple incompetent veins is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested Stab phlebectomy of varicose veins and injection of sclerosant of 
multiple incompetent veins. 
 
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 Stab phlebectomy of varicose veins and 
injection of sclerosant of multiple incompetent veins. Our reviewer says that the enrollee does not meet criteria 
for the requested Stab phlebectomy of varicose veins and injection of sclerosant of multiple incompetent veins. 
Our physician reviewer found the record indicates that the enrollee has varicose veins. The record provided is 
insufficient to establish that the elements of the coverage criteria have been satisfied. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stab phlebectomy of varicose veins and injection of sclerosant of multiple 
incompetent veins have not been met. Therefore, we decided that the Plan does not have to pre-approve Stab 
phlebectomy of varicose veins and injection of sclerosant of multiple incompetent veins.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Uvulectomy (42140). 
 
You asked the Plan to pre-approve a Uvulectomy (42140). You say that the requested Uvulectomy (42140) is 
medically necessary. The Plan denied your request. The Plan says the requested Uvulectomy (42140) is 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 pre-approve a Uvulectomy (42140). Our reviewer 
says that the requested Uvulectomy (42140) is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has globus sensation. There is insufficient literature to support the safety and 
efficacy of the requested service for the enrollee's condition. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 Uvulectomy (42140) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Uvulectomy (42140).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25290 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 25290. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 25290 is bundled into payment for code 25607. 
 
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 25290 is a column II code to column I code 25607. This claim 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 25290 billed for date of service June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic mattress (E1399). 
 
You asked the Plan to pre-approve an orthopedic mattress. You say that the enrollee received a mattress with a 
tear. You disagree with the denial and are requesting reconsideration. The Plan denied your request. The Plan 
says the requested mattress is not covered by the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that an orthopedic mattress is not covered by the 
plan.  
 
While an orthopedic mattress 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 an orthopedic mattress (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 23, 
2022, to March 2, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that when a beneficiary receives outpatient hospital 
services during the day immediately preceding the hospital admission, the outpatient hospital services are 
treated as inpatient services. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were performed beyond the 
three day payment window for outpatient hospital services treated as inpatient. 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 inpatient hospital services rendered from February 23, 2022, to March 2, 
2022.
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 enrollee has a past medical history of multiple 
comorbidities with weakness. The Plan denied your request. The Plan says the SNF admission 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 there is no clear recommendation for daily skilled therapy or skilled nursing 
services. The enrollee would be able to discharge to home setting with supervision. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this procedure is experimental and is not covered. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and 
efficacy when used as bone graft material. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate (20939).
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. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Remicade, infliximab, Inflectra or Simponi Aria. 
 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 the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no 
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided April 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 find that CPT code 81455 is not supported in the medical record. Specifically, the claim was 
billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was 
collected on April 11, 2022, rather than the billed date of service April 24, 2022. The date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for targeted 
genomic sequence analysis, 51 or greater genes (81455) provided April 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000) provided on November 30, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under the enrollee's 
contractual policy or by Medicare for his condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  Additionally, with the exception of the situations described above, orthopedic footwear billed using code 
L3000 will be denied as non-covered. Therefore, we decided that the Plan does not have to pay for the foot 
orthotics (L3000) provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid 
analysis for lymphedema assessment (93702 x 4). 
 
You asked the Plan to pre-approve BIS assessments. You say that the enrollee is at high risk for developing 
lymphedema. You say that the use of the ImediMed L-Dex device is medically necessary. You also say that 
quarterly visits are necessary according to the lymphedema prevention protocol. The Plan denied your request. 
The Plan says the requested service is 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 pre-approve BIS assessments. Our reviewer says 
that the requested BIS assessments are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the current role of bioimpedance spectroscopy remains uncertain. Therefore, the 
reviewer found that the requested BIS assessments are not medically reasonable or 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 BIS assessments have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema 
assessment (93702 x 4).