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 enrollee would benefit from an 
admission to a Long Term Acute Care Hospital to regain a maximum/prior level of functioning and continue 
multidisciplinary approach to care. The Plan denied your request. The Plan says the enrollee may adequately 
receive the care needed in the current location. 
 
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. 
 
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 a Freestyle continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle CGM sensor. You say that you disagree with the denial. The 
Plan denied your request. The Plan says you do not meet criteria for approval of the requested sensor. 
 
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 insulin with at least 
three daily injections or 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 CGM sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle continuous 
glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the requested accessory is not covered because it not primarily 
medical in nature, The item is not medically necessary. 
 
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 a power seat elevation system (E2300).
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 service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. 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 the enrollee does not use insulin 
with at least three daily injections and does 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 the 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you disagree with the denial. 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 76642 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 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845) and an addition, endoskeletal system, above knee or hip disarticulation, 
knee extension assist (L5850). 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced knee feature. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the requested replacement prosthetics do not meet 
Medicare criteria as reasonable and 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 a prosthetic leg with an advanced knee 
feature. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a level 3 ambulator has the ability or potential for 
ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most 
environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic 
utilization beyond simple locomotion. It is standard that after a below-the-knee amputation heals, a preparatory 
prefabricated prosthesis is provided to help achieve limb maturation and total contact and to avoid multiple 
socket changes. In this case, the documentation does not support that the enrollee requires the advanced knee 
that is requested. The health plan has authorized an appropriate prosthesis. 
 
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 prosthetic leg with an advanced knee feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845) and an addition, endoskeletal system, above knee or hip disarticulation, knee 
extension assist (L5850).
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 an admission to an LTACH facility is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342 and 88360 billed for date of 
service January 17, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342 and 88360. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 88341, 88342 and 88360 have not been met. Specifically, the records suggest that 
these services were rendered in an outpatient facility. Procedure codes 88341, 88342 and 88360 have a 
professional/technical component indicator of 1. This means that these codes have a professional and technical 
component. These codes have not been billed with the appropriate modifier to indicate that they are for the 
professional component. Payment for the technical component of these codes is included in the payment to the 
facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88341, 88342 and 88360 billed for date of service January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-57 provided on June 21, 2022. 
 
You asked the Plan to pay for procedure code 99232-57. You say that the medical records support the use of 
modifier 57 for code 99232 provided on June 21, 2022. The Plan denied your request. The Plan says the 
medical records do not support the use of modifier 57 for code 99232 provided on June 21, 2022. 
 
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 99232-57 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder 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 procedure code 99232-57. Our reviewer says that the medical 
records do not support the use of modifier 57 for code 99232 provided on June 21, 2022. The provider did not 
mention a plan for future surgery in their note and there is no evidence that a decision for surgery was 
performed as part of this evaluation and management service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99232-57 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232-57 provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac genetic screening testing performed on July 13, 2021. 
 You asked the Plan to pay for the cardiac genetic screening testing. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says screening genetic tests are not 
covered. 
 
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 cardiac genetic screening testing, was requested solely for screening 
purposes. The medical records clearly state this was for screening to determine if the patient has a genetic 
predisposition for cardiac disease.  The medical records go on to state that the patient is asymptomatic. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for cardiac genetic screening testing performed on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Icatibant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not a covered benefit. 
 
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 Icatibant.  
 
Benefits for these services 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 a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee is being treated 
with insulin using one injection per day and the enrollee is not using an insulin pump. The enrollee is currently 
treated with the requested product. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested sensor. 
 
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 or 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 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (61322) provided on June 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 61322 is "Craniectomy or craniotomy, decompressive, 
with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated 
intraparenchymal hematoma; without lobectomy". 
 
We asked our coder 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 services. Our reviewer says that the use of code 61322 is 
not supported by the records provided. Our reviewer found that while the operative report contains 
documentation of a partial suboccipital craniectomy, there is insufficient documentation of intracranial 
hypertension. 
 We looked at this coder'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 pay for the services (61322) provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that all requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested item is not a 
covered accessory because it is not primarily medical in nature. 
 
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 a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pay for the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant. 
You say that this testing is medically necessary to develop the most appropriate treatment plan for the enrollee. 
The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant have not been met. 
Therefore, we decided that the Plan does not have to pay for F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided April 26, 2021. 
 
You asked the Plan to pay for laboratory services. You say that due to the global pandemic, your billing 
department was understaffed. The other reason for the reconsideration request is in October 2021, your billing 
system was a victim of a ransomware attack. The Plan denied your request. The Plan says the claim was 
received past the timely filing limitation. 
 
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 laboratory services was not filed until May 12, 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 the laboratory services provided April 26, 2021.