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

 
We decided that the Plan does not have to pre-approve specially sized or constructed wheelchair (E1220). 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee recently fell out of their 
wheelchair due to the broken arm rest in which it did cause injury to the enrollee. The Plan denied your request. 
The Plan says the customized wheelchair, specially sized or constructed, the provider is requesting does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the wheelchair have not been met. In order for the requested item 
or service to be covered, the enrollee would need to have: provider notes showing the base for this wheelchair is unique and truly customized. The enrollee's records show the base requested is a manual tilt and recline 
wheelchair which is not made from raw materials or needs large changes. Therefore, we decided that the Plan 
does not have to pre-approve specially sized or constructed wheelchair (E1220).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 you do not qualify for SNF coverage. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in this way 
and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. Based 
on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that records do not show the enrollee is part of a Medicare approved clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the percutaneous image-guided lumbar decompression have not been met. Specifically, the 
enrollee is not enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, trunk (CPT code E0656), segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the information they have been provided does not show that the enrollee has used a 
basic pump daily for at least four weeks. The Plan states the records do not provide leg measurements before 
and after the four-week trial showing that the basic pump did not help their lymphedema. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve segmental pneumatic appliance for 
use with pneumatic compressor, trunk (CPT code E0656), segmental pneumatic appliance for use with 
pneumatic compressor, full leg (E0667) and pneumatic compressor, segmental home model with calibrated 
gradient pressure (E0652).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve Monoferric. The Plan denied your request. The Plan says the enrollee has 
not tried and failed Infed (iron dextran) and Venofer (iron sucrose). 
 
 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 Monoferric. Our physician reviewer 
found that the enrollee has iron deficiency anemia. The Plan requires a trial of Infed and Venofer before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is 
no documentation provided indicating that the Plans required drugs would likely be less effective or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable 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 payment for the billed services is not supported. Specifically, codes G0402 and G0463 were billed 
on the same date of service with Revenue Code 0510. This returns OCE Edit 42, which indicates that a claim 
reported with multiple medical visits on the same date of service with same revenue code must include condition code G0. The appropriate condition code was not billed in this case, therefore the claim was denied. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services provided on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 home ventilator is medically 
necessary. The Plan denied your request. The Plan says your records do not show that your noninvasive 
ventilator is being used with settings that are any different from what can be supplied with a bilevel positive 
airway pressure (BiPAP) machine. 
 
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 a home ventilator is not medically necessary.  You have severe COPD but does not have 
chronic carbon dioxide (CO2) retention. The partial pressure of carbon dioxide (PaCO2) was normal.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service 
November 19, 2021. 
 You asked the Plan to pay for procedure codes 99152 and 99153. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 99152 and 99153 is bundled into 
payment for code 77263. 
 
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 codes 
99152 and 99153 are column II codes to column I code 77263. 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 99152 and 99153 billed for 
date of service November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturoapath non-face-to-face telephone services provided on 
March 7, 2022. 
 
You asked the Plan to pay for naturoapath non-face-to-face telephone services. You say that you have been ill 
for about 25 years and you could not find any help with your primary care physician, which you have changed 
many times due to the lack of help received. The Plan denied your request. The Plan says naturopaths are not 
qualified for Medicare reimbursement and are therefore not eligible for coverage for Medicare-covered 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturoapath non-face-to-face telephone services provided on March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization (CPT code(s): 37227, 37231, 37221). 
 
You asked the Plan to pre-approve the revascularization. You say that you have a family history of heart 
disease and all family members have passed due to this condition. You state that you are unable to walk due to 
severe pain and have multiple blockages in your left leg. The Plan denied your request. The Plan says your 
records do not show you have significant narrowing or blockage of your arteries being treated and you have 
serious condition or complications due to lack of blood flow (critical leg ischemia). The Plan states neither do 
they show you have tried and failed conservative treatment (maximal medical treatment or GDMT) or there are 
medical reasons you cannot take this treatment. 
 
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 revascularization. Our physician 
reviewer found the documentation does not support the medical necessity of the treatments in question. The 
request for additional angiography and treatment of the left lower extremity is not supported by noninvasive 
imaging including recent lower extremity arterial Doppler studies or pulse examination. It is unclear why 
images of the left lower extremity were not obtained during the angiogram in July if you were having 
significant claudication. Additionally, the providers recommendation was for you to continue current therapy 
with a recommendation for a walking program to try to improve exercise tolerant and encouraged to walk as 
much as possible. There is no documentation that these measures have been attempted and failed. 
 
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 revascularization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization (CPT code(s): 37227, 37231, 37221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your 
mobility needs. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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.  
 
The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power operated vehicle.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (29826) provided November 4, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were 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 29826 is not supported in the medical record. Specifically, this service is a packaged 
service and is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical services (29826) provided November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (81227XS, 
81230XS, 81231XS, 81232XS, 81306XS, 81328XS, 81355XS, 81335XS, 81291XS, 0031UXS, 0032XU, 
0033UXS, 81238XS) provided March 22, 2022. 
 
You asked the Plan to pay for cardiac risk assessment genetic screening testing. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests/panels for suspected or 
documented cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for cardiac risk assessment genetic screening testing (81227XS, 81230XS, 
81231XS, 81232XS, 81306XS, 81328XS, 81355XS, 81335XS, 81291XS, 0031UXS, 0032XU, 0033UXS, 
81238XS) provided March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel, solid organ 
neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for 
sequence variants and copy number variants or rearrangements (the genetic test, Onco50) (81445). 
 
You asked the Plan to pre-approve the testing. You say that the testing is necessary. The Plan denied your 
request. The Plan says the enrollee's request is not medically necessary because their records show this 
requested lab test is not listed on the list of approved FDA companion diagnostic tests. The Plan states the 
enrollee's records also say that the enrollee is receiving palliative treatment. 
 
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 testing. Our physician reviewer 
found the review has determined that the medical records provided did not meet the requirements listed in the 
NCD for Medicare coverage. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA 
analysis when performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, 
PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number 
variants or rearrangements (the genetic test, Onco50) (81445).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PBT ((CPT) code(s): 77523, 77525, 77522, G6002). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiation of the prostate is not appropriate for patients with extensive metastatic disease. Also, 
there is insufficient prospective, long-term clinical data available to determine whether or not proton beam 
radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, 
intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. The most 
recent American Urological Association (AUA) guidelines state that PBT offers no clinical advantage over 
other forms of definitive treatment. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PBT ((CPT) code(s): 77523, 77525, 77522, G6002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine rendered on October 27, 2021. 
 
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 procedure code 90471 is not supported. 
 
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 90471 is immunization administration (includes 
percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination 
vaccine/toxoid). 
 
We find that CPT code 90471 is not supported in the medical record. Specifically, the records show that an 
influenza vaccine was administered and there is a more appropriate code for these services. 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 influenza vaccine rendered on October 27, 2021.