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

 
We decided that the Plan does not have to pre-approve a prosthetic leg. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is a duplicate and non-covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee was approved for a prosthesis on March 28, 2022. The requested prosthesis 
serves the same purpose as the approved prosthesis. Therefore, we decided that the Plan does not have to pre-
approve a prosthetic leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one year of continuous glucose monitor (CGM) 
supplies. 
 
You asked the Plan to pre-approve one year of CGM supplies. 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. 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of one year of 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve one year of 
continuous glucose monitor (CGM) supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal distraction device. 
 
You asked the Plan to pre-approve insertion of a spinal distraction device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of a spinal distraction device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found spinal distraction devices are experimental in spinal surgery. More 
research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a spinal distraction device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of a spinal distraction device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance (76937), fluoroscopic guidance 
(77001), and catheter insertion (36558) provided on August 13, 2021. 
 
You asked the Plan to pay for the diagnostic services. You say that the enrollee revoked their hospice election 
prior to the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ultrasound 
guidance (76937), fluoroscopic guidance (77001), and catheter insertion (36558) provided on August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent ambulance transportation. 
 
You asked the Plan to pre-approve non-emergent ambulance transportation. You say that you require medical 
transport due to a medical condition that inhibits you to drive for over 8 years. The Plan denied your request. 
The Plan says a physician's office or a physician office that is attached to a Critical Access Hospital (CAH) are 
not-covered destinations. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of non-emergent ambulance 
transportation. have been met. Medical records were not provided with this case to show that the non-emergent 
transportation is medically necessary. Therefore, we decided that the Plan does not have to pre-approve non-
emergent ambulance transportation.
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 enrollee needs IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the enrollee is medically stable with no new and acute medical problems, does not need physical medicine and rehabilitations physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no 
acute rehabilitation nursing needs identified or documented in the record. The enrollee does not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The enrollee, with an uncomplicated hip fracture, does not need IRF admission. The 
enrollee's rehabilitation needs can be met safely and provided at a lower intensity and alternate setting such as 
in a skilled nursing facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 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 health 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show failure to respond to at least four weeks of treatment directed by 
the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you have had 
chronic low back pain for at least sixteen years. There is no trauma. The notes during the visit of 4/19/22 
indicate that you have failed physical therapy and epidural steroids. However, there are no details as to when 
these things have occurred. The attached records offer no details. In addition, the notes indicate you had an 
MRI on 11/4/20, which showed scoliosis and multi-level degenerative changes. There are no details offered as 
to what has changed symptomatically since that prior MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (CPT) code 99215 to be provided by a 
tertiary care provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you had a previous visit with the 
requested provider and had treatments. You state that you also cant wait over 30 days to see your Oncologist 
as a cancer patient. The Plan denied your request. The Plan says the services can be done safely with their 
preferred (main) network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the review has 
determined that there is no evidence in the record to support that you require the expertise of the tertiary level 
provider or if this is something that could be managed by the plans non-tertiary oncology providers. 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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office visit (CPT) code 99215 to be provided by a tertiary care 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on November 1, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this was medically necessary testing that is 
covered by Medicare. The Plan denied your request. The Plan says this was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare 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 NGS panel was billed on two separate claims using multiple 
individual gene codes. This is not correctly billed per Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the Tempus gene panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus gene panel provided on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance-guided focused ultrasound 
(MRgFUS). 
 
You asked the Plan to pre-approve the magnetic resonance-guided focused ultrasound (MRgFUS). You say that 
the service is medically necessary. The Plan denied your request. The Plan says this service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for this service. 
 
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 magnetic resonance-guided focused 
ultrasound (MRgFUS). Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the member does not meet criteria for coverage of this service. 
 
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 magnetic resonance-guided focused ultrasound (MRgFUS) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance-guided focused 
ultrasound (MRgFUS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on August 30, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan 
does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on August 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on July 6, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was billed with the incorrect 
POS code. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services (G0483) provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis. 
 
You asked the Plan to pre-approve knee orthosis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830), or a knee 
orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). 
 
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 knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found provided records do not document 
recent injury to the knee or a recent surgical procedure on the knee (last documented surgery was March 2021) 
or knee instability documented by examination with objective description of joint laxity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthosis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on March 23, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The requested CxBladder test was billed with code 0012M. Per the 
LCD, this code is not covered for CXBladder testing. 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 pay 
for the CxBladder testing (0012M) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on August 30, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed correctly. 
 
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 95907 
is a column II code to column I code 95861 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for neurology services provided to the enrollee on August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) myelogram of the lumbar 
spine. 
 
You asked the Plan to pre-approve the myelogram. You say that this is medically necessary. The Plan denied 
your request. The Plan says unless surgery is planned, then this request is premature. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 myelogram. Our reviewer says that 
the requested imaging is not medically reasonable or necessary. Our physician reviewer found you are unable 
to have magnetic resonance imaging (MRI) due to a pacemaker. The recent CT of the lumbar spine without 
intrathecal contrast revealed stenosis and degenerative changes. The notes state that you recently completed a 
physical therapy (PT) program, but no notes or documentation regarding the same are in the records. There 
must be physical documentation of the failure of the physical therapy within the past six months. Until this is 
provided, this request cannot be considered 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 the myelogram have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) myelogram of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (thyroid), mRNA, gene expression analysis of 
593 genes (0204U) provided on December 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this 
testing was medically necessary. The Plan denied your request. The Plan says this provider is not in-network 
and the services were not referred by an in-network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oncology (thyroid), mRNA, gene expression 
analysis of 593 genes (0204U) provided on December 11, 2021, by an out-of-network (OON) provider.