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

 
We decided that the Plan does not have to pay for lab services (G0482) provided December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 lab 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 lab services (G0482) provided December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine and administration provided on December 
21, 2021. 
 
You asked the Plan to pay for the TDAP vaccine. You say that the doctor said you need to get this, and it was 
free. You say that this should have been free, and you dont understand why you have a bill. The Plan denied 
your request. The Plan says the diagnosis code is not appropriate for this vaccine. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine and administration provided on 
December 21, 2021.  
 
  Benefits for the TDAP vaccine 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 pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. The Plan denied your request. The Plan says a knee scooter 
is not considered medically necessary. 
 
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. There is insufficient published clinical literature demonstrating 
safety and effectiveness Based on this information, we decided that Medicare rules for coverage of a knee 
scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) and Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 
(K0554) provided November 29, 2021. 
 
 You asked the Plan to pay for the CGM device and supplies. You say that you have already given the services 
to the enrollee. Authorization is not required because the enrollee has out of network benefits. The Plan denied 
your request. The Plan says the records do not support that the enrollee meets the Medicare criteria. 
 
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 pay for the CGM device and supplies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Plan requires multiple daily injections with insulin dose adjustments based on BG 
level. The records submitted as above do not include this data to support multiple insulin shots/d with 
adjustments in doses based on BG level. It appears as if the enrollee is only using oral medications, hence the 
criteria for 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 the CGM device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for supply allowance used with a therapeutic CGM device (K0553) and Receiver 
(monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) provided November 
29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging, breast, without and with 
contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and 
pharmacokinetic analysis), when performed; bilateral (77049) provided on November 14, 2021. 
 You asked the Plan to pay for Magnetic resonance imaging, breast, without and with contrast material(s), 
including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic 
analysis). The Plan denied your request. The Plan says the MRI does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that breast MRI studies are to be used very selectively. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Magnetic resonance imaging, breast, without 
and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, 
characterization and pharmacokinetic analysis). Our reviewer says that the breast MRI is not medically 
necessary. Our physician reviewer found that the provided records document that MRI was performed for 
screening and not for a case where the diagnosis is inconclusive, even after standard work-up; evaluation of the 
post-operative patient when scar tissue cannot be differentiated from tumors; patients with positive axillary 
nodes but no known primary; patients with rupture of a breast implant; or determination of the extent of disease 
in patients with known malignancy, prior to treatment (to assure confinement to one segment of the breast). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Magnetic resonance imaging, breast, without and with contrast material(s), 
including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic 
analysis) have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance 
imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time 
lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (77049) provided 
on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair power seat elevation system. You say that you need this 
item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low vision aids. 
 
You asked the Plan to pre-approve low vision aids. You say that the request will help with reading and the 
enrollee's quality of life. The Plan denied your request. The Plan says low vision aids are not covered by 
Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 We looked at the file and the rules. Medicare does not pay for low vision aids, including all devices that use 
one or more lenses to aid vision or magnify images. Therefore, we decided that the Plan does not have to pre-
approve low vision aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says you have exhausted the benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for an additional 24 routine transportation trips. 
 
You asked the Plan to provide coverage for an additional 24 routine transportation trips. The Plan denied your 
request. The Plan says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips 
per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for an additional 24 routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional aquatic therapy visits (97113). 
 
You asked the Plan to pre-approve aquatic therapy. You say that these services are medically necessary, and 
the enrollee's decline in function is due to an increase in activity at home. The Plan denied your request. The 
Plan says the enrollee's active range of motion for extension, flexion and left/right side bending are all 
unchanged from March 16, 2022, and the lower extremity functional scale is worse than it was during prior 
evaluation in March. Based on this information, the requested therapy is not medically necessary and does not 
meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 aquatic therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided records do not document that the aquatic therapy has 
facilitated progression to land-based exercise or increased function as required by Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight (8) additional aquatic therapy visits (97113).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Personal Emergency Response System (PERS). 
 
You asked the Plan to pre-approve a PERS. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Personal Emergency Response System (PERS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device. 
 
You asked the Plan to pre-approve the requested device. You say that the device is necessary after prostate 
surgery. The Plan denied your request. The Plan says the device is non-covered. 
 
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 requested device is not covered by Medicare or your plan. 
Therefore, we decided that the Plan does not have to pre-approve a vacuum erection device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not covered prior to a knee replacement 
surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are covered 
for patients who have received a total knee replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a continuous passive motion device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous passive motion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the clinical documentation does not support the need for the non-invasive ventilator (E0466) rather than the bilevel positive airway pressure (BiPAP) with back-up rate (E0471), which 
has been approved for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator. Our reviewer says 
that  Our physician reviewer found  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator with very low set 
volumes (150-200 ml) aimed at assisting respiration that could be equally delivered by BiPAP with AVAPS is 
not covered. The plan would consider approval of an E0471 upon request. 
 The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve the portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that the enrollee has weeping edema 
with venous stasis ulcers. The Plan denied your request. The Plan says there is no active wound that meets 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
We looked at the file and the rules. The records do not show that the enrollee has a qualifying wound. This 
means that the enrollee does not have a medical condition for which compression stockings can be covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the enrollee has developed alopecia. The Plan denied 
your request. The Plan says a wig is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99221) provided on March 15, 2021. 
 
You asked the Plan to pay for initial hospital care (99221). You say that the claim should be reconsidered with 
the attached documents and reprocessed for payment. The Plan denied your request. The Plan says only one 
code from this pair may be 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. In this case, we have confirmed that code 99221 
is a column II code to column I code 99223 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 initial hospital care (99221) provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee presents with scarring and 
truncal swelling. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
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 requested device. Our physician 
reviewer found that the record indicates the enrollee has lower extremity lymphedema with truncal edema. The 
record does not indicate that she has tried and failed a trial with a basic pump as required by the coverage rules.  
Therefore, the elements of the coverage criteria are not satisfied. 
 
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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided on August 30, 2021. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions. The Plan 
denied your request. The Plan says chiropractic manipulation of one or more of the extra-spinal regions is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided on August 30, 2021.