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

 
We decided that the Plan does not have to reimburse you for a wig (A9282) purchased February 26, 2022. 
 
You asked the Plan to reimburse you for a wig. You say that you were informed that a wig was a covered 
benefit when you called and checked on the benefit and was mailed the reimbursement form. You needed a wig 
as the hair loss was really bad and needed help. The Plan denied your request. The Plan says the criteria was 
not met for wig coverage. Your hair loss is due to Alopecia. The Plan covers wigs for hair loss due to treatment 
for Cancer. 
 
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 reimburse you for a wig 
(A9282) purchased February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Over Bed Table and Recliner Chair. 
 
You asked the Plan to pre-approve an Over Bed Table and Recliner Chair. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items are not primarily medical in nature. 
 
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 an Over Bed Table and Recliner Chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you feel this 
equipment is necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested 
items. 
 
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 a pneumatic compression device 
(E0652) and appliances (E0667 and E0656).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide. 
 
You asked the Plan to pre-approve Budesonide. The Plan denied your request. The Plan says outpatient 
prescription drugs are not covered. 
 
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 Budesonide.  
 
 
 Benefits for Budesonide 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 pay for the elbow orthosis (L3761) provided August 25, 2022. 
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted documentation does not reveal support for an elbow orthosis. Physical exam 
findings indicate normal range of motion, normal strength, no weakness and ability to perform activities of daily living independently. There is no detailed elbow exam or clear indication for the need for this brace. The 
elbow orthosis (L3761) is not medically 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the elbow orthosis (L3761) provided August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis, in situ hybridization (88374) 
provided June 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please let the attached documentation service 
to support medical necessity of the testing performed and to justify the services. The Plan denied your request. 
The Plan says missing the signature of provider of service or supplier. 
 
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 88374 is Morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), using computer- assisted technology, per specimen; each multiplex probe stain procedure. 
 
We find that CPT code 88374 is not supported in the medical record. Specifically, the rendering provider's 
information was not provided on the claim form. A corrected claim is needed that includes the rendering 
provider's information. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for 
morphometric analysis, in situ hybridization (88374) provided June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation to go back and forth to your dialysis appointments three times per week. The Plan denied your 
request. The Plan says this service is a covered benefit, but you have exceeded the limits set in the subscriber 
agreement for additional routine transportation. 
 
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 up to 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 pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 10, 
2021, through October 12, 2021, at the Diagnosis Related Group (DRG) 309 originally billed. 
 You asked the Plan to pay for the acute inpatient hospital care billed at DRG 309. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that 
the clinical evidence provided does not support the diagnosis code indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N39.0 as defined by a urinary tract 
infection, not specified. 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 acute inpatient 
hospital care at DRG 309 originally billed. Our reviewer says that the acute inpatient hospital care provided 
were not billed correctly. The records do not support diagnosis code N39.0 (urinary tract infection) as the 
clinical presentation, review of systems, and physical examination findings did not suggest a urinary tract 
infection (no symptoms or findings) and the gold standard urine culture was not performed or resulted to 
confirm the suspected infection. The clinical picture as a whole is needed in order to diagnose a urinary tract 
infection, not simply urinary analysis findings that did not match the clinical picture. Therefore, the DRG of 
310 would be most appropriate for this admission.   
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the acute inpatient hospital care provided from October 10, 2021, through October 12, 2021, at the 
Diagnosis Related Group (DRG) 309 originally billed.
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 you were independent before entering the hospital 
and want to return independent. You are eager to participate and complete the required daily 3 hours of therapy 
you will not receive in a nursing home. The Plan denied your request. The Plan says your ongoing skilled 
therapy and nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility, on an 
intermittent basis at home with home health care, or in a long-term care setting. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641) provided on October 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that CPT code 76641 
has an MUE value of 1, but 2 units were billed. 
 
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 argues that code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that a bilateral diagnostic 
procedure may be reported with 1 unit of service with modifier RT on 1 claim line plus 1 unit of service 
and modifier LT on a second claim line, as was done in this case. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (76641) provided 
on October 4, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Celecoxib. 
 
You asked the Plan to pre-approve Celecoxib. You say that you have been on this for years. The Plan denied 
your request. The Plan says the drug is not covered under the medical benefit for your condition. 
 
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 Celecoxib.  
 
 
 Benefits for Celecoxib 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 pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on August 24, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the date on the proof of delivery does not match the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The date on the 
proof of delivery does not match the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (CGM) supplies (K0553), provided on August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous fixation device (zip) procedure for the 
indication of lumbar pain (22612). 
 
You asked the Plan to pre-approve a zip procedure. You say that the enrollee's physician says medical necessity 
is supported for this procedure. The Plan denied your request. The Plan says the long-term safety and efficacy 
of this procedure has not been established in the peer reviewed literature and therefore this procedure would be 
considered investigational which is not covered by Medicare. The Plan also says that additionally, it would not 
meet the Medicare definition of reasonable and necessary for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a zip procedure. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows the requested 
interspinous fixation device (zip) procedure (22612) at L5-S1 to be an effective and/or safe treatment for the 
noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. Our reviewer also found that there is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 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 zip procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous fixation device (zip) procedure for the indication of lumbar pain (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 99213. The Plan denied your request. The Plan says payment for 
code 99213 is bundled into payment for code 20610.  
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 99213 
is a column II code to column I code 20610. 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 99213 billed for date of service September 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac (SI) joint. 
You say that radiofrequency ablation of the nerves innervating the sacroiliac (SI) joint is medically necessary. 
The Plan denied your request. The Plan says radiofrequency ablation of the nerves innervating the sacroiliac 
(SI) joint is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation of the nerves 
innervating the sacroiliac (SI) joint. Our reviewer says that the requested radiofrequency ablation of the nerves 
innervating the sacroiliac (SI) joint is not considered medically reasonable and necessary. Our physician 
reviewer found that radiofrequency ablation of the lateral sacral branches is considered experimental because of 
the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically 
reasonable and 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 radiofrequency ablation of the nerves innervating the sacroiliac (SI) joint have 
not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the 
nerves innervating the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Leneva Allograft Adipose Matrix injection. 
 
You asked the Plan to pre-approve the Leneva Allograft Adipose Matrix injection. You say that the Leneva 
Allograft Adipose Matrix injection is medically necessary. You say that your hope is for relief across the 
bottom and sides of your feet where excessive loss of tissue has compromised your mobility and health. The 
Plan denied your request. The Plan says the requested Leneva Allograft Adipose Matrix injection is 
experimental and 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 Leneva Allograft Adipose Matrix 
injection. Our reviewer says that the Leneva Allograft Adipose Matrix injection is not considered medically 
reasonable and necessary. Our physician reviewer found that Allograft adipose matrix (AAM) is the 
extracellular matrix component of allograft adipose tissue after the lipid and the cellular components have been 
removed. When properly processed, the endogenous components (matrix proteins, growth factors, cytokines) 
are preserved. Your physician is requesting the use of Leneva. This product is considered unproven. The 
evidence is lacking. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Leneva to established treatments are needed. Published studies do not demonstrate any long-term 
health outcome advantage with the use of Leneva as an alternative to standard treatments. The review has 
determined that the requested Leneva Allograft Adipose Matrix injection in this case is not medically 
reasonable and 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 Leneva Allograft Adipose Matrix injection have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Leneva Allograft Adipose Matrix injection.