Persius/hicric huggingface dataset:
Appeal type: Transportation
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 would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee has used all 24 one-way trips 
for the 2022 benefit year and additional trips will not be approved. 
 
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 transportation 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an Ultrasound (76641). 
 
You asked the Plan to pre-approve an Ultrasound (76641). You say that the requested Ultrasound is medically 
necessary. The Plan denied your request. The Plan says that there were no medical records provided for review. 
 
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. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested Ultrasound (76641). Therefore, 
we decided that the Plan has to pre-approve an Ultrasound (76641).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 14, 2022 billed with 
codes 0031U, 0032U, 0033U, 81226, 81227, 81230, 81231, 81232, 81306, 81335, & 81355. 
 
You asked the Plan to pay for the genetic testing billed. 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. The 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 was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 14, 2022 billed with codes 0031U, 0032U, 0033U, 81226, 81227, 81230, 81231, 81232, 81306, 
81335, & 81355.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81162, 81201, 81292, 81295, 81298, 81314, 81317, 
81321, 81334, 81351, 81479) provided March 8, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that this panel included the BLM genetic test which is non-covered based 
on Local Coverage Articles. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a 
diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical 
Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and 
when coverage requirements are met. 
 
We looked at the file and Medicare rules. The plan's denial is based solely upon Medicare Local Coverage 
Article: Billing and Coding: MolDX: BLM Gene Analysis (A55113). The Local Coverage Article is 
insufficient justification to deny a nationally-covered service. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (81162, 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, 81479) 
provided March 8, 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 Trelegy Ellipta. 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Trelegy Ellipta is not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Ellipta.  
 
 Benefits for Trelegy Ellipta 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 reflectors. 
 
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 services are not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve reflectors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin pump (E0784). 
 
You asked the Plan to pre-approve an insulin pump. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the C-peptide level requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of an insulin pump requires either a 
positive beta cell autoantibody test or a C-peptide level less than or equal to 110 percent of the lower limit of 
normal of the laboratory's measurement method. 
 
We looked at the file and Medicare rules. The submitted records do not include beta cell autoantibody test, and 
the enrollees C-peptide level was greater than 110 percent of the lower limit of normal of the laboratory's 
measurement method. Based on this information, we decided that Medicare rules for coverage of an insulin 
pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an insulin pump 
(E0784).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
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 services are not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway pressure 
(CPAP) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on October 1, 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 you billed with an incorrect place of service on the claim. 
 
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 (G0483) provided on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breath hydrogen or methane test to diagnose small 
intestinal bacterial overgrowth (SIBO) (91065). 
 
You asked the Plan to pre-approve a breath test for SIBO. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth and measuring small bowel transit time is not covered. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breath test for SIBO have not been met. Therefore, we decided that the Plan does not have to pre-
approve breath hydrogen or methane test to diagnose small intestinal bacterial overgrowth (SIBO) (91065).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after August 26, 
2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee needs continued rehab to 
function as she was prior to her fractures. The Plan denied your request. The Plan says continued SNF care 
after August 26, 2022, is not medically necessary. 
 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 continued SNF care. Our reviewer says 
that continued SNF care is not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing facility (SNF) care after August 26, 2022.
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 to return to prior level of 
function. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs 24 hour care and therapy to 
recover. The Plan denied your request. The Plan says based on Medicare guidelines the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 the enrollee was admitted for mental status changes and slurred speech with no 
evidence found of new stroke. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is noncovered 
since does not meet the definition of a prosthesis. Based on this information, we decided that Medicare rules 
for coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a mastectomy sleeve (L8010).
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 the ventilator. You say that BiPAP does not supply targeted ventilation that 
will adjust to changing pressure requirements quickly enough for a patient of this severity. The Plan denied 
your request. The Plan says the criteria for the requested ventilator have not been met. 
 
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 ventilator. Our reviewer says that 
the requested device is not considered reasonable and necessary. Our physician reviewer found the enrollee has 
chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and severe obesity with alveolar 
hypoventilation. The enrollee was admitted to the hospital on 8/8/22. As of 8/22/2022, it is documented in the 
pulmonary note that the enrollee had been trying to use a continuous positive airway pressure (CPAP) device but is only able to wear it for a few hours before needing to take it off. In the hospital, the enrollee was using 
bilevel PAP (BiPAP). The ventilator is being requested to deliver BiPAP with average volume assured pressure 
support (AVAPS). A ventilator is not covered when used only for this indication. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an angioplast and stent. 
 
You asked the Plan to pre-approve an angioplast and stent. You say that an angioplast and stent is medically 
necessary. The Plan denied your request. The Plan says an angioplast and stent does not meet the Medicare 
LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 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 an angioplast and stent. Our reviewer 
says that an angioplast and stent is not medically necessary. Our physician reviewer found that the enrollee is 
interested in treatment for erectile dysfunction, which would be a pelvic arteriogram with evaluation of the 
penile artery, and angioplasty if flow limiting stenosis is confirmed. He has a long history of erectile 
dysfunction, which has persisted despite medication and injection treatments. Initial request for pelvic 
arteriogram with angioplasty was denied as unproven. The review has determined that  the requested angioplast 
and stent does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angioplast and stent have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an angioplast and stent.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea injections. 
 
You asked the Plan to pre-approve Eylea injections. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says they confirmed with the provider that the Eylea injection is 
not buy and bill. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Eylea injections.  
 
Benefits for Eylea injections 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer System (Vertiflex). 
 
You asked the Plan to pre-approve the Superion Interspinous Spacer System (Vertiflex). You say that the 
Superion Interspinous Spacer System (Vertiflex) is medically necessary. The Plan denied your request. The 
Plan says based on the references available, the use of this device continues to be 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 Superion Interspinous Spacer 
System (Vertiflex). Our reviewer says that the Superion Interspinous Spacer System (Vertiflex) is not 
considered medically reasonable and necessary. Our physician reviewer found that the enrollee has chronic low 
back pain with radiation into her legs. She has tried medication, physical therapy, injections, and a spinal cord 
stimulator. These have not provided a durable improvement in her symptoms. She has requested a Vertiflex 
procedure for her pain. Decompression surgery of the lumbar spine has been considered, but the enrollee is not 
interested. Interspinous spacers are a less-invasive treatment alternative compared with surgical decompression 
for patients with LSS unresponsive to conservative care. High-quality comparative data with these devices are lacking. The review has determined that the Superion Interspinous Spacer System (Vertiflex) at issue in this 
case is not 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 Superion Interspinous Spacer System (Vertiflex) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Superion Interspinous Spacer System 
(Vertiflex).