Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member has a need for medically 
necessary acute care services provided at an LTACH. The Plan denied your request. The Plan says the member 
does not meet the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enteral formula, for adults used to replace fluids and 
electrolytes (e.g., clear liquids), 500 ml = 1 unit (code B4102). 
 
You asked the Plan to pre-approve Enteral formula, for adults used to replace fluids and electrolytes  
(e.g., clear liquids), 500 ml = 1 unit. You say that this is medically necessary. The Plan denied your request. 
The Plan says the requested service is not covered by Medicare or the health Plan. Enteral formula, for adults, 
used to replace fluids and electrolytes taken by mouth is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered, no benefit. 
 
We looked at the file and Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered, no benefit. Therefore, we decided that the Plan 
does not have to pre-approve Enteral formula, for adults used to replace fluids and electrolytes  
(e.g., clear liquids), 500 ml = 1 unit (code B4102).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided October 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (breast), mRNA, microarray gene expression 
profiling of 70 content genes and 465 housekeeping genes (81521) and unlisted molecular pathology procedure 
(81479) provided November 25, 2022. 
 
You asked the Plan to pay for the MammaPrint testing. You say that MammaPrint is a proprietary test and is 
not available through any other laboratory provider. The Plan denied your request. The Plan says 81521 is 
denied automatically as not medically necessary and records were not provided records to establish medical 
necessity for CPT code 81479. 
 
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 MammaPrint testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee, has Oncotype on breast tissue and was started 
on Tamoxifen in May 2022. The enrollee was seen by an Oncology nurse practitioner in November 2022. 
Tamoxifen was discontinued and a MammaPrint test was ordered. According to Medicare Local Coverage 
Determination (LCD) L35000 guidelines states "Genetic testing procedures submitted under the following 
Current Procedural Terminology (CPT) codes 81521are unlikely to impact therapeutic decision-making in the 
clinical management of the patient and will be denied automatically as not medically necessary. The review has 
determined that the records do not support the medical necessity criteria for Medicare coverage. 
 
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 MammaPrint testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the oncology (breast), mRNA, microarray gene expression profiling of 70 content 
genes and 465 housekeeping genes (81521) and unlisted molecular pathology procedure (81479) provided 
November 25, 2022.
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  The Plan denied your request. The Plan says 
there is insufficient information provided to approve these services. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. In this case medical records were needed to review this request. The Plan requested this information, but it was not 
received. Without this information we are unable to verify whether criteria are met for coverage of SSBCI 
benefits. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 16, 2022 to 
August 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted as 
required, and these claims should be paid. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 16, 2022 to August 
14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that the enrollee has essential tremors preventing 
him from using lancets safely. The Plan denied your request. The Plan says the criteria for coverage are not 
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 treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99211 billed for date of service September 28, 2022. 
 
You asked the Plan to pay for code 99211. You say that this code may be reported by professionals other that 
physicians. The Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that codes billed on an outpatient hospital bill with a 
status indicator of B are not recognized by the Outpatient Prospective Payment System (OPPS). This applies to 
codes submitted on an outpatient hospital bill (bill type 12x and 13x). These codes may be billed on other bill 
types and alternate codes may be available when submitted on an outpatient hospital bill type.  
 
In this case, the code at issue (99211) has a OPPS status indicator of B.  It was billed on an outpatient hospital 
bill type (131).  This code is not payable when billed on this bill type.  Another code may be available for this 
service. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99211 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99211 billed for date of service September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care (CPT 99222), a swallowing function 
x-ray (CPT 74230) and an upper gastrointestinal tract x-ray (CPT 74240) provided on November 11, 2022. 
 
You asked the Plan to pay for inpatient hospital care (CPT 99222), a swallowing function x-ray (CPT 74230) 
and an upper gastrointestinal tract x-ray (CPT 74240). You say that the services were medically necessary and 
there were no contracted providers that could have provided the services. The Plan denied your request. The 
Plan says this service is not a covered benefit under the members Plan and is not eligible for reimbursement 
per the Medicare Benefit Policy Manual; Chapter 15 80.4.4. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient hospital care (CPT 99222), a swallowing function x-ray (CPT 74230) and an upper 
gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided that the Plan does not have 
to pay for inpatient hospital care (CPT 99222), a swallowing function x-ray (CPT 74230) and an upper 
gastrointestinal tract x-ray (CPT 74240) provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on October 10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you have provided medical records to show 
the necessity of these services. The Plan denied your request. The Plan says you did not bill the multiple visits 
with the required condition code, so the entire claim denied. 
 
The Plan must follow Medicare rules. Medicare rules say that hospitals must report Condition Code G0 when 
multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and 
constituted independent visits. 
 
In this case, you billed multiple medical visits on the same date of service in the same revenue center (codes 
G0463 and G0402).  Although you billed with the 25 modifier, you did not bill with the required condition 
code of G0 needed for outpatient hospital claims.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for outpatient services provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation and management service (99443) 
provided on November 10, 2022. 
 
You asked the Plan to pay for a telephone evaluation and management service. You say that this is separately 
payable. The Plan denied your request. The Plan says this was billed on the same day as another evaluation and 
management service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Administrative Contractors (MACs) 
may not pay two evaluation and management (E/M) office visits billed by a physician (or physician of the same 
specialty from the same group practice) for the same beneficiary on the same day unless the physician 
documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter 
 
We looked at the file and Medicare rules. The record shows that this service was billed on the same day for the 
same beneficiary by the same physician as E/M code 99214. There is no documentation that this service was 
for unrelated problems. Based on this information, we decided that Medicare rules for coverage of a telephone 
evaluation and management service have not been met. Therefore, we decided that the Plan does not have to 
pay for a telephone evaluation and management service (99443) provided on November 10, 2022.
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. You say that this medication is used for a nebulizer. You also 
say that this is for use with the enrollee's home nebulizer. The Plan denied your request. The Plan says the 
requested drug is 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 pre-approve the personal emergency response system (S5161). 
 
You asked the Plan to pre-approve the personal emergency response system. You say that you have 2 different 
types of cancer, and you are afraid of being alone. The medication you take can make you sleepy. You use a 
walker, but your strength is failing which also puts you at risk to fall. The Plan denied your request. The Plan 
says this item is not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the personal emergency response system (S5161).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services billed for date of service 
November 3, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you have provided medical records 
to support payment of this claim. The Plan denied your request. The Plan says there is a billing error on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99352 has an Outpatient Prospective 
Payment System (OPPS) status indicator of 'M', meaning that it is not payable under OPPS. 
 
Because of how OPPS payments are calculated, if there is an error on the claim, the entire claim will deny until 
that error is fixed.  In this case, you included code 93352 on the claim.  Code 93352 is not an OPPS-payable 
code, which is causing an error in calculating the claim payment.  This code would need to be removed or 
changed in order for the OPPS payment to be calculated. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services billed for date of service November 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that please approve the request for the 
mentioned procedure. Supporting clinical notes are attached. The Plan denied your request. The Plan says there 
are not enough studies to show that Vertiflex Superion is safe and effective to treat back pain. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental for back pain. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion device (22869).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on October 17, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that more than 
22 drug classes were tested, including Alkaloids-not otherwise specified, Amphetamines, Antidepressants-
serotonergic class, Antidepressants-tricyclic and other cyclicals, Antidepressants-not otherwise specified, 
Barbituates, Benzodiazepines, Buprenorphine, Cocaine, Fentanyls, Gabapentin-non-blood, Heroin metabolite, 
Methadone, Methylenedioxyamphetamines, Methylphenidate, Opiates, Opioids and opiate analogs, 
Oxycodone, Phencyclidine, Pregabalin, Propoxyphene, Sedative Hypnotics (non-benzodiazepines), Skeletal 
muscle relaxants, Tapentadol, and Tramadol. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0483 have been met. Therefore, we decided that the Plan has to pay for procedure 
code G0483 provided on October 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prodigy test strips. 
 
You asked the Plan to pre-approve Prodigy test strips. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Prodigy test strips. Therefore, we decided that the Plan does not have to pre-approve Prodigy test strips.