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

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of a therapeutic CGM 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to an LTACH. 
 
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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, and 0033U. 
 
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 
February 16, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $96.36 deductible for an office visit on May 2, 2022. 
 
You asked the Plan to waive the $96.36 deductible for an office visit. You say that you should not be 
responsible for this because the claim was filed incorrectly. The Plan denied your request. The Plan says 
deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a combined deductible of $1000 which applies to an office visit.  
 
 
 
 
 
 
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a combined deductible of $1000 which applies to 
Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation 
that had not been met at the time this claim was processed. Therefore, we decided that the Plan does not have to 
waive the $96.36 deductible for an office visit on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve a group 2 power wheelchair. You say that you need the power wheelchair 
because pain and swelling of your left foot prevent you from walking on it. The Plan denied your request. The 
Plan says you reside in a home setting that will not allow the ingress/egress with a power wheelchair. The Plan 
also says you are a limited functional ambulator in the home setting and your status is likely to change after 
surgery. 
 
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 you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group 2 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator x 12 (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the concentrator is medically 
necessary due to COPD. The Plan denied your request. The Plan says the oxygen concentrator is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an oxygen concentrator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you have chronic obstructive pulmonary disease.  The record 
indicates that you have a room air oxygen saturation of 96%. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator x 12 (E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from March 30, 2021, to March 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says this was appropriate at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services provided to the enrollee from March 30, 2021, to 
March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve a BIS. You say that you believe the enrollee was at high risk of developing 
lymphedema and the use of ImpediMed's L-Dex technology was medically necessary to monitor the enrollee. 
The Plan denied your request. The Plan says experimental and investigational procedures are 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 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 BIS. Our reviewer says that the BIS is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the currently 
available evidence does not include sufficient high-quality studies that more certainly conclude that this form 
of testing is superior to other screening methods and leads to long-term clinical outcomes better than others. It 
is not the standard of care currently. Our reviewer found that therefore, this request for bioimpedance testing 
will be considered not medically necessary at this time. 
 
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 BIS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a bioimpedance spectroscopy (BIS) (93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic manipulative treatment (98941). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your request for continued chiropractic treatment is 
considered maintenance therapy which is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 this service. Our reviewer says that 
continued chiropractic treatment is not medically necessary. Our physician reviewer found that in this case, the 
record indicates that you have lumbar subluxation and have received twenty two treatments this year. The 
records of these visits do not support progressive improvement of symptoms but rather maintenance therapy. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued chiropractic manipulative treatment (98941).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of the genicular nerve branches of the knee 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is considered experimental/investigational and its role in the therapy of knee 
osteoarthritis is still being evaluated. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction of the genicular nerve branches of the knee for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tomographic myocardial perfusion imaging (MPI) 
(78452). 
 
You asked the Plan to pre-approve an MPI. You say that a pharmacological stress test is needed to better 
evaluate ongoing complaints of substernal chest pain that the enrollee has described in recent office notes. The 
Plan denied your request. The Plan says the pharmacological nuclear stress test or pharmacological myocardial 
perfusion imaging requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that the rationale for selecting pharmacologic stress rather 
than exercise stress must be indicated in the medical record. 
 
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 MPI. Our reviewer says that an MPI 
is not reasonable and necessary. Our physician reviewer found there is no documentation that the 
electrocardiogram shows an uninterpretable pattern or that exercise on a treadmill cannot be carried out. There 
is no evidence provided that would support the need for radionuclide stress testing. Our reviewer also found 
that there is insufficient documentation to support the medical necessity for the requested cardiac stress testing 
in this enrollees clinical management. 
 
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 MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a tomographic myocardial perfusion imaging (MPI) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, injections, and Acupuncture (93000, 
20553, 97813) provided on February 7, 2022 to March 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram, injections, and acupuncture. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they were non-emergent and prior authorization was not obtained. 
 
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 pay for 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 pay for an electrocardiogram, injections, and Acupuncture 
(93000, 20553, 97813) provided on February 7, 2022 to March 31, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 provided on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 
You asked the Plan to pre-approve Monoferric. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Monoferric. Our reviewer says that the 
requirements for coverage of Monoferric have not been met. Our physician reviewer found the Plan requires a 
trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. The record 
does not indicate that the enrollee has tried and failed these drugs. There is also no indication that these drugs 
would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (J1437).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, and 81355. 
 
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 
February 7, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 
81328, 81335, and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified molecular pathology procedure (81479) 
billed for December 21, 2021. 
 
You asked the Plan to pay for the pathology procedure. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service was billed with 
several other codes for genetic testing which was submitted on a different claim form, but all testing was 
performed on the same specimen. The testing in this case would all be part of one panel, and the use of 
modifier 59 is inappropriate in a situation where all testing was performed on a single specimen. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 pathology procedure have been met. 
Specifically, the record shows that the Plan has already paid for testing services (81194, 81311, 81317) 
provided on December 19, 2021. It is unclear why this testing is separate and there is no indication that another 
specimen was collected or obtained for the additional services billed. Therefore, we decided that the Plan does 
not have to pay for the unspecified molecular pathology procedure (81479) billed for December 21, 2021.