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

 
We decided that the Plan does not have to pre-approve KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral 
oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) (81273) and unlisted molecular 
pathology (genetic testing) (81479). 
 
You asked the Plan to pre-approve KIT gene analysis, D816 variant and unlisted genetic testing. You say that 
the enrollee needs this testing. The Plan denied your request. The Plan says there is no documentation of a 
diagnosis of germline cancer or a diagnosis of somatic cancer that is recurrent, relapsed, refractory, metastatic 
or in advanced stage. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered for enrollees with germline cancer or 
somatic cancer that is recurrent, relapsed, refractory, metastatic or in advanced stage. 
 
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 KIT gene analysis, D816 variant and 
unlistsed genetic testing. Our reviewer says that the criteria for coverage are not met. Our physician reviewer 
found that the documentation does not support that the enrollee in this case has either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of KIT gene analysis, D816 variant and unlistsed genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve KIT (v-kit Hardy-Zuckerman 4 feline 
sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) (81273) and unlisted 
molecular pathology (genetic testing) (81479).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 04, 2022. 
 
You asked the Plan to pay for the medical services. You say that these are covered codes and this claim should 
be paid. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the medical services 
provided on August 04, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve zolpidem tartrate. 
 
You asked the Plan to pre-approve zolpidem tartrate. You say that the requested drug is medically necessary to 
treat the enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 zolpidem tartrate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (90870) provided on September 30, 2022. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90870 is not supported in the medical record. Specifically, the claim was not billed with 
a valid diagnosis code. Diagnosis Code F06.1 is not a valid primary diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for therapy services (90870) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that the enrollee has been advised to check 
their blood sugar frequently throughout the day, which is why you have prescribed the CGM. The Plan denied 
your request. The Plan says a CGM is not covered for an enrollee who is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics, interpretation 
and report (88291) provided on July 28, 2022. 
 
You asked the Plan to pay for the cytogenetics and molecular cytogenetics. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there is no evidence to support the 
referring/ordering provider is/was treating the enrollee. 
 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 Plan made multiple attempts to contact the referring provider 
listed on the claim for additional information. No response was received. There is no evidence to support the 
referring/ordering provider is treating the patient. Based on this information, we decided that Medicare rules for 
coverage of the cytogenetics and molecular cytogenetics have not been met. Therefore, we decided that the 
Plan does not have to pay for the cytogenetics and molecular cytogenetics, interpretation and report (88291) 
provided on July 28, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 78815 billed for date of service January 13, 2022. 
 
You asked the Plan to pay for procedure code 78815. You say that procedure code 78815 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says payment for 
code 78815 is bundled into payment for code 78816. 
 
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 says procedure code 78815 is considered inclusive to procedure code 
78816 and cannot be paid separately. The Plan did not submit documentation supporting that procedure code 
78816 was billed on the same date of service by the same provider as procedure code 78815. It is the burden of 
the Plan to substantiate their decision with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for procedure code 78815 billed for date 
of service January 13, 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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says 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 your medical status does not require intensive physician and nursing oversight in an 
IRF. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Icosapent Ethyl capsules. 
 
You asked the Plan to pre-approve Icosapent Ethyl capsules. The Plan denied your request. The Plan says the 
requested drug is not of a type and/or used for a condition that is covered under the medical 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 Icosapent Ethyl capsules.  
 
  Benefits for Icosapent Ethyl capsules 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88365 billed for 
date of service January 27, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88365. You say that these services 
are supported as billed. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88365. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88365. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88365 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88365 billed for date of service January 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flex. 
 
You asked the Plan to pre-approve Tresiba Flex. The Plan denied your request. The Plan says Tresiba Flex is 
on the self-administered drug list, and is excluded from coverage under Part B. 
 
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 Tresiba Flex.  
 
  Benefits for Tresiba Flex 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 provide a continuous glucose monitor (CGM). 
 
You asked the Plan to provide a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 provide a continuous glucose monitor (CGM). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the criteria for a CGM 
coverage are not 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 a continuous glucose monitor (CGM) have not been met. Therefore, we decided 
that the Plan does not have to provide a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that any device that does not include alarms and battery 
backup is not sufficient. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic assisted therapy device (MyoPro). 
 
You asked the Plan to pre-approve MyoPro. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has left upper extremity partial paralysis after suffering a stroke during an 
astrocytoma right temporal lobe tumor resection in 2014. The MyoPro Orthosis is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The 
MyoPro is not the standard of care for this enrollee's condition or in widespread use for this enrollee's condition 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this enrollee.  There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. 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 MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a robotic assisted therapy device (MyoPro).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33210 billed for date of service May 11, 
2022 to May 13, 2022. 
 
You asked the Plan to pay for procedure code 33210. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 33210 is bundled into payment for code 33235. 
 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 33210 
is a column II code to column I code 33235. 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 33210 billed for date of service May 11, 2022 to 
May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a lumbar-sacral orthosis, sagittal-
coronal control, with rigid anterior and posterior frame/panels (L0637) provided on September 30, 2021. 
 
You asked the Plan to pay an additional amount for a lumbar-sacral orthosis. You say that you disagree with 
the out of network reimbursement rate for the medical services that were given to the enrollee. The 
reimbursement rate is unreasonably low, and you are requesting an increased payment to be granted. The Plan 
denied your request. The Plan says payment was made according to the Medicare allowable rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a lumbar-sacral orthosis have not been met. Specifically, the record indicates that the Plan has paid 
the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. Therefore, we decided that the Plan does not have to pay an additional amount for 
a lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels (L0637) 
provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the home ventilator. Our physician 
reviewer found if the enrollee does have chronic carbon dioxide (CO2) retention, may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. This has not been tried and failed as an outpatient. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 74176 is bundled into payment for code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service May 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone billed with code G2078 
for September 26, 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 provider cannot bill for these services. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028.  
 
We looked at the file and Medicare rules. The file shows that code G2078 was not billed by a provider enrolled 
as an OTP. 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 take-home supply of methadone 
billed with code G2078 for September 26, 2022.