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

 
We decided that the Plan does not have to pay for the genetic testing provided on September 29, 2021 billed 
with codes 81479 and 81161. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
September 29, 2021 billed with codes 81479 and 81161.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
  You asked the Plan to pre-approve SNF care. You say that it has been recommended that the enrollee receive 
an SNF placement because they have a weakened status and need further therapy to gain strength. The Plan 
denied your request. The Plan says there are no skilled nursing needs identified. The Plan also says that the 
enrollee's needs can be appropriately met either with discharge home and intermittent skilled outpatient 
therapy, or if socially necessary with placement into a custodial non-skilled setting for activities of daily living 
assistance. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy needs. 
The enrollee is consistently ambulating more than 100 feet. Our reviewer also found that 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
14, 2021. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Red Elephant scooter. 
 
You asked the Plan to pay for the Red Elephant scooter. You say that you do not want a power chair because 
they are not big enough. You say that the power wheelchair you previously received had a joystick that was too 
sensitive. You say that the requested scooter you want is $2,000 less than the power wheelchair you were 
approved for. The Plan denied your request. The Plan says the provider for the requested type of scooter is not 
a Medicare approved durable medical equipment provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a Red Elephant scooter.
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 are very weak in your legs and he need therapy. 
The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested 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 enrollee's orthostasis limits his rate of recovery, and it is not an indication for 
an inpatient hospital stay. Our physician reviewer also found that the enrollee does not require frequent 
physiatry oversight to monitor his orthostasis and does not have other complexities. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
appealing the denial of coverage for a pneumatic compression device. The Plan denied your request. The Plan 
says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-
week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
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 segmental pneumatic appliances (E0656, E0667).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
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 inpatient rehabilitation facility. The enrollee continues 
to have a need for an inpatient level of care at the hospital and would currently be unable to participate in 
intensive rehabilitation services. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD and OHS. The Plan denied your request. The Plan says that the Plan says the request for a home 
mechanical ventilator set in iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not 
covered. 
 
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 a home ventilator. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the enrollee has neuromuscular disease, 
thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
The clinical documentation supports that the requested home ventilator is medically reasonable and necessary 
for the enrollee at this time. There is no documentation to suggest a BiPAP with backup rate and AVAPS was 
utilized and failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99214) all subsequent annual 
wellness visits (G0439) annual depression screening (G0444) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the outpatient visit. You say that you are requesting the Plan cover your 
visits, as well future visits to provide you a continuance of care. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99214) all subsequent annual wellness visits (G0439) annual depression screening 
(G0444) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two power wheelchair. 
 
You asked the Plan to pre-approve a group two power wheelchair. You say that you disagree with the Plan's 
denial. 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 group two power wheelchairs are not a covered 
benefit.  
 
We looked at the file and Medicare rules. Review of the file shows that the request is for a group two power 
wheelchair. This item is specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of a group two power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group two power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
device (K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM) device (K0554).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Tymlos before they will approve the requested drug, Evenity. There is no indication that the patient has 
tried and failed the required drug. Based on the medical records provided and the Medicare-approved major 
drug compendia there is no indication that the plan's required drug would likely be less effective and/or likely 
have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repetitive transcranial magnetic stimulation (rTMS) 
treatment (90867) and the initial therapeutic repetitive transcranial magnetic stimulation (TMS) treatment 
(90868, 90869). 
 
You asked the Plan to pre-approve the repetitive transcranial magnetic stimulation (rTMS) treatment (90867) 
and the initial therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90868, 90869). You 
say that are appealing with supporting records. The Plan denied your request. The Plan says based on Medicare 
guidelines, the services being requested (90867, 90868, 90869) do not meet the requirements for approval. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The rules say 
that transcranial magnetic stimulation is only covered 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 the repetitive transcranial magnetic 
stimulation (rTMS) treatment (90867) and the initial therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment (90868, 90869). Our reviewer says that the enrollee does not meet the criteria for repetitive 
transcranial Magnetic Stimulation (rTMS). Our physician reviewer found the enrollee has generalized anxiety 
disorder. Our physician reviewer also found that there is no documentation of depression or treatment 
resistance, there is no documentation of the patient's response to psychotherapy, and there is no documentation 
of this patient undergoing previous Transcranial Magnetic Stimulation (TMS) or Electroconvulsive Treatment 
(ECT). 
 
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 repetitive transcranial magnetic stimulation (rTMS) treatment (90867) and 
the initial therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90868, 90869) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the repetitive transcranial magnetic 
stimulation (rTMS) treatment (90867) and the initial therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment (90868, 90869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a telephone-alert system. 
 
You asked the Plan to pre-approve a telephone-alert system. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that telephone-alert systems are not 
covered because they are emergency communications systems and do not serve a diagnostic or therapeutic 
purpose.  
 
While a telephone-alert system may be appropriate in this case, neither the Plan nor Medicare offers coverage 
of this item. Therefore, we decided that the Plan does not have to pre-approve a telephone-alert system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electron-beam computed tomography (EBCT). 
 
You asked the Plan to pre-approve an EBCT. The Plan denied your request. The Plan says this procedure is not 
medically necessary. 
 
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 an EBCT. Our reviewer says that an 
EBCT is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is 
insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the 
heart with quantitative evaluation of coronary calcium in guiding optimal management of this enrollee. Our 
reviewer found that as such, CT imaging of the heart without contrast material with quantitative evaluation of 
coronary calcium is considered experimental/investigational for the evaluation and management of this 
enrollee's medical 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 an EBCT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electron-beam computed tomography (EBCT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pain management consultation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the specialist consultation. You say that one of your friends got the iO-
CoreTM stem cell injection and the procedure improved your friends knee pain. You also say that the iO-
CoreTM stem cell injection is not offered by the orthopedic department of the clinic. The Plan denied your 
request. The Plan says the rules clearly state you must receive services from in-network providers. The Plan 
also says that pain management consultations can be rendered by in-network providers. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pain management consultation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2).