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

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies provided on 
September 23, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the enrollee is a longstanding diabetic with 
multiple insulin injections who has been using the CGM system since March of 2022. You say that shipping 
history has been included. The Plan denied your request. The Plan says the medical records provided did not 
include valid proof of delivery. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, both the shipping and delivery dates on the 
proof of delivery document provided do not match the date of service billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for continuous glucose monitor (CGM) supplies provided on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. 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, for 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 June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 18, 2022 to 
May 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 April 18, 2022 to May 
17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic test strips and lancets at a utilization amount of 100 per 3 
months. 
 
You asked the Plan to pre-approve diabetic test strips and lancets. You say that you are appealing this denial. 
The Plan denied your request. The Plan says that there is not enough evidence to support the need to test at this 
frequency. 
 
The Plan follows Medicare rules. Medicare rules state that diabetic testing supplies may be covered if certain 
criteria are met. 
 
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 diabetic test strips and lancets. Our 
reviewer says that you meet criteria for the requested utilization level of diabetic test strips and lancets. Our 
physician reviewer found you have uncontrolled diabetes. From your statement it appears as if your doctor has 
advised more frequent checks to help you improve blood glucose control and perhaps to decide on and titrate 
doses of additional medication. This is reasonable for a patient that is about to undergo surgery and has an A1C 
of 9.8%. Glipizide can cause low blood glucose so additional testing seems appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diabetic test strips and lancets have been met. Therefore, we decided that the 
Plan has to pre-approve diabetic test strips and lancets at a utilization amount of 100 per 3 months.  
 
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 a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that you disagree with the denial. 
The Plan denied your request. The Plan says experimental and investigational procedures are not covered by 
Medicare. The use of the upper limb orthotic known as the MyoProTM is unproven and not medically necessary 
due to insufficient evidence of safety and/or efficacy. 
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Trodelvy intravenous solution reconstituted 180mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no support in the Medicare-approved compendia or peer-reviewed medical 
literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that th eenrollee has 
received or cannot tolerate recommended for the first line. The enrollee has poor tolerance for Capecitabine. 
The use of this drug for triple negative breast cancer is considered safe, effective, reasonable, and 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Trodelvy intravenous solution reconstituted 180mg.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 15, 2022, to 
May 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 rendered from May 15, 2022, to May 
31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 Sensor. 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 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 
Freestyle Libre Kit 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Kit 2 Sensor.
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 services are necessary to ensure enrollee reaches 
a full recovery. The Plan denied your request. The Plan says the enrollee could receive care in another setting. 
 
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 does not require physician supervision three times a week. There are 
no acute skilled nursing or skilled rehab needs identified. Intensive therapies (three hours of therapy, at least five days per week) is not required with a multidisciplinary approach. Needs can be provided for in a lower 
intensity and alternate setting such as in a skilled nursing facility. 
 
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 pay for electrical stimulator supplies (A4595) provided on August 
17, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that you disagree with the denial and are 
requesting payment for this claim. The Plan denied your request. The Plan says the denied services are not a 
covered benefit as there is no evidence to support the ordering provider ordered the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The records show that the Plan reached out to the ordering 
providers office on November 7, 2022, asking if the requested items were ordered. The providers office 
responded that the enrollee does not have an electrical stimulator on file. Medicare rules require that a written 
order/prescription from the treating practitioner is a condition for payment. Therefore, we decided that the Plan 
does not have to pay for electrical stimulator supplies (A4595) provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the requested services. The Plan denied your request. The Plan says the requested procedure is unproven 
and not medically necessary due to insufficient evidence of efficacy. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 76641 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 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 10, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiogram (93306) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an echocardiogram to be provided by an OON provider. 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 
an echocardiogram (93306) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on August 23, 2022. 
 
You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that the referring provider 
determined this testing to be medically necessary. The Plan denied your request. The Plan says ordering a 
multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical management, exceeds 
the needs of the enrollee. 
 
The Plan follows 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 definitive UDT for 22 or more drug classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the submitted 
documentation indicates that the enrollee is treated for chronic pain with morphine, oxycodone and gabapentin. 
No screening drug test results are submitted. The definitive drug screen testing for 22 or more drug classes is 
not medically 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 definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on September 2, 2022. 
 
You asked the Plan to pay for medical supplies. You say that this item is medically necessary and is covered. 
The Plan denied your request. The Plan says there is no evidence that the patient's provider ordered this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the Plan 
contacted the provider you contend ordered this item, and they stated that there is no order on file for this 
patient for this item. There is no note in the medical records either showing the provider's intent to order this 
item for the patient. Therefore, we decided that the Plan does not have to pay for medical supplies provided on 
September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to March 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 February 27, 2022, to 
March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed rendered on February 23, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed rendered on February 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 17, 2022, to 
July 29, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed correctly. 
 
The Plan follows Medicare rules. The rules say that certain data elements are required on the submitted claim. 
 
We reviewed the file and the Medicare rules. We find that the services were not billed with a required Q code. 
This means the claim is not payable as billed. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from July 17, 2022, to July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81479) provided on August 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was needed to make treatment 
decisions for the enrollee. The Plan denied your request. The Plan says there was insufficient information 
available to review this claim. 
 
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 the lab services have been met. 
Specifically, the Plan reached out to the provider for medical records. These were not provided. Without the requested medical records, we are unable to determine whether this service was medically necessary.  
Therefore, we decided that the Plan does not have to pay for the lab services (81479) provided on August 30, 
2021.