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

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 4, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment is 
not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment provided on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 catheters (A4352) per a month. 
 
You asked the Plan to pre-approve the additional catheters. You say that the items are medically necessary. The 
Plan denied your request. The Plan says there is no submitted clinical information to support the medical 
necessity for additional A4352 catheters. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the additional catheters have not been met. Specifically, there is no indication as to why additional 
catheters would be medically necessary. The Plan approved the maximum of 200 catheters per a month and the 
medical records provided indicate that is enough. Therefore, we decided that the Plan does not have to pre-
approve an additional 100 catheters (A4352) per a month.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis C antibody screening (G0472) provided on 
August 31, 2022. 
 
You asked the Plan to pay for the Hepatitis C screening. You say that this is a covered preventative screening. 
The Plan denied your request. The Plan says Hepatitis C screenings are not covered for enrollees who do not 
meet certain criteria. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Hepatitis C screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Hepatitis C antibody screening (G0472) provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use a CSII pump, and 
you do not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based 
on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 sensor kit have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 Response testing (81479) provided on January 
12, 2022. 
 
You asked the Plan to pay for Guardant360 response. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test has not yet completed review under the MolDX program. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as currently being under 
review. This means that the test at issue has not yet completed the process in order to be eligible for coverage. 
Based on this information, we decided that Medicare rules for coverage of Guardant360 response have not been 
met. Therefore, we decided that the Plan does not have to pay for Guardant360 Response testing (81479) 
provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve power seat elevation feature. You say that the enrollee needs this feature. 
The Plan denied your request. The Plan says the requested power seat elevation feature is 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. 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 power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed with two units for date of 
service March 30, 2022. 
 You asked the Plan to pay for the two units of procedure code 0003A. You say that this should be paid. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the two 
units of procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed with two units for date of service March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a pneumatic compressor and a full leg segmental pneumatic appliance. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 pneumatic compressor (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667) 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 hyperbaric oxygen (HBO) therapy (G0277) and physician attendance and supervision (99183).

You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to certain conditions.

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 HBO therapy and physician attendance. Our reviewer says that the services are not medically necessary. Our physician reviewer found a wound care visit dated March 28, 2023, indicated wound cultures and inflammatory markers were not available. There is no specific clinical rationale for the requested hyperbaric oxygen therapy. The review indicates that the enrollee does not meet the coverage criteria detailed in the NCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician attendance and supervision (99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have high blood pressure, respiratory 
issue, and heart problems. You also say that your provider was supposed to send you to see a pulmonary 
specialist to check your respiratory. The Plan denied your request. The Plan says the criteria for eligibility have 
not been met. 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve daily image-guided radiation therapy (IGRT).

You asked the Plan to pre-approve daily IGRT. You say that the enrollee had a large epidural mass in her lumbosacral area, thus an extensive extraosseous component of disease. You say that it is not a simple bone met. You say that IGRT is required and that this is a continuation of therapy that started as inpatient. The Plan denied your request. The Plan says daily imaging is not medically necessary for palliative radiation therapy.

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 daily IGRT. Our reviewer says that daily IGRT services are not considered medically reasonable and necessary in this case. Our physician reviewer found for radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary to escalate the dose, particularly when using very high dose per fraction, or when critical normal
tissues abutting the target necessitate daily image guidance to allow minimal planning margins to spare the normal tissue. For the palliative treatment of bone metastases, even when there is extra-osseous extension (as is the case for this patient) the use of IGRT is generally considered not medically necessary outside of a medically plausible rationale. In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. The presence of extraosseous disease is not an accepted indication for IGRT. It appears IGRT is simply being used as routine practice, as there does not seem to be any exceptional circumstances with this patient necessitating the need for IGRT. IGRT is not an accepted standard of care for routine use in the palliative treatment of bone metastases.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of daily IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve daily image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure 
(CPAP) machine and a humidifier. 
 
You asked the Plan to pre-approve a replacement CPAP machine and a humidifier. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested devices are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP is covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file does not include medical records that support that 
the enrollee meets the adherence to therapy criteria. The medical records provided were largely incomplete to 
support the necessity of these devices. Based on this information, we decided that Medicare rules for coverage 
of a replacement CPAP machine and a humidifier have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a replacement continuous positive airway pressure 
(CPAP) machine and a humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you were able to use this benefit last year, but 
do not understand why it is being denied now, and your health condition has not changed. The Plan denied your 
request. The Plan says the criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast prosthesis, mastectomy bra (L8000) and 
breast prosthesis, silicone or equal, without integral adhesive (L8030)} to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the breast prosthesis. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available to perform this service. 
 
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 breast prosthesis, mastectomy bra (L8000) and breast prosthesis, silicone or equal, without integral 
adhesive (L8030)} 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 vehicle lift for a scooter (E1399). 
 
You asked the Plan to pre-approve a vehicle lift for a scooter. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a vehicle lift for a scooter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve. 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that your right arm is twice the size of your 
left arm. The Plan denied your request. The Plan says the item is not covered by Medicare. 
 
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 mastectomy sleeve does not meet the definition of a 
prosthesis. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power operated vehicle (E1399) purchased May 17, 2022. 
 
You asked the Plan to pay for a power scooter. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the records do not support that the request was medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair, and you cannot 
safely operate the PMD being requested. The records do not show a home evaluation was completed, proof of 
payment or that there is an order for a power operated vehicle. The Plan made multiple attempts to obtain needed additional records without success. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have to pay for a power operated vehicle (E1399) 
purchased May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, shoulder (code 73030) provided on 
July 15, 2021. 
 
You asked the Plan to pay for the radiologic examination, shoulder. You say that the claim was submitted 
timely. The Plan denied your request. The Plan says a corrected claim must be receive within one year  
(12 months) from the processed date of the original claim submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the radiologic examination, shoulder was not filed until October 27, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a radiologic examination, shoulder (code 73030) 
provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a transplant center to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON transplant consultation. You say that you feel that the OON 
provider should be approved as they have a much shorter wait time for the organ you require. You feel that at 
your age, waiting longer is not an option. The Plan denied your request. The Plan says the in-network provider 
is able to provide the organ needed within the same time frame as would be available under Original Medicare 
for your area. At this time, there is no medical reason for OON care. 
 
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 pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pre-approve a consultation with a transplant center to be 
provided by an out-of-network (OON) provider.