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

 
We decided that the Plan has to pre-approve a stance flexion feature (L5845) for the OttoBock 3R93. 
 
You asked the Plan to pre-approve the feature. You say that the current prosthetic knee and foot are no longer 
under warranty. The Plan denied your request. The Plan says that the approved knee does not require L5845. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The approved knee unit - the Otto 
Bock 3R93 - does not have a specific listing. There are no official approved codes for the requested unit. The 
plan has not provided solid evidence that L5845 is not an appropriate part of this knee. Therefore, we decided 
that the Plan has to pre-approve a stance flexion feature (L5845) for the OttoBock 3R93.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis services (81455). 
 You asked the Plan to pre-approve targeted genomic sequence analysis services. You say that this genetic 
testing is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for 
coverage of the requested genetic testing services have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that next generation sequencing genetic testing services 
are subject to the criteria listed 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 targeted genomic sequence analysis 
services. Our reviewer says that the requested genetic testing services are not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 62-year-old female diagnosed with thyroid cancer in 
2007. In this case, the patient with a history of non-small cell lung cancer in 1991 now has a new primary 
physician. The patient may have up to a IIB (T2N0) disease and if that case testing for Epidermal Growth 
Factor Receptor (EGFR) is indicated. However, given low stage full next generation sequencing is not 
indicated according to National Comprehensive Cancer Network Guidelines. The service is not reasonable or 
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 targeted genomic sequence analysis services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve targeted genomic sequence analysis services (81455).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82274, 82656, 82705, 83520, 83631, 87177, 
87209, 87338, 87798, 89055). 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 (82274, 82656, 82705, 83520, 83631, 87177, 87209, 87338, 
87798, 89055).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee has been diagnosed with recurrent platinum refractory ovary cancer. According to medical 
literature found in the Journal of the American Medical Association in this phase 2 nonrandomized clinical 
trial, the combination of pembrolizumab with bevacizumab and oral cyclophosphamide was well tolerated and 
demonstrated clinical benefit in 95.0% and durable treatment responses (>12 months) in 25.0% of patients with 
recurrent ovarian cancer. The requested drug is medically reasonable and necessary for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that you provide services in good faith. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
 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. This claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery. 
 
You asked the Plan to pre-approve the Vertiflex Superion device placement surgery. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 Superion device 
placement surgery. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this service is experimental and more research is needed 
to show its safety and efficacy. 
 
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 Superion device placement surgery have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary to 
determine the enrollee's course of treatment. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 18, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer board. 
 
You asked the Plan to pre-approve a transfer board. You say that the item will assist in transferring the enrollee 
who is an amputee. The Plan denied your request. The Plan says the item 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 transfer board.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infliximab drug assay identified with code 80230 provided 
on June 24, 2021. 
 
You asked the Plan to pay for Infliximab drug assay. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 80230 is Inflixima. 
 
We find that CPT code 80230 is not supported in the medical record. Specifically, the documentation shows 
that this code was billed twice on the same date of service under two different claims. The documentation 
submitted does not support two separate services were performed. Based on this information, we decided that Medicare rules for coverage of Infliximab drug assay have not been met. Therefore, we decided that the Plan 
does not have to pay for Infliximab drug assay identified with code 80230 provided on June 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
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 records do not show the enrollee's condition will probably 
require an average 25 day length of stay in 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 enrollee 
was admitted with respiratory failure in the setting of pneumonia. The record indicates that the enrollee is 
improving but still requires ongoing acute care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator (SCS) procedure (63650, 
L8680). 
 
You asked the Plan to pre-approve the spinal cord stimulator (SCS) procedure. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 spinal cord stimulator (SCS) 
procedure. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
patient does not have an evidence based indication for a SCS trial and has several options available that have 
not been tried. 
 
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 spinal cord stimulator (SCS) procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the spinal cord stimulator (SCS) procedure (63650, L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar sacral facet joint radiofrequency neurolysis. 
 
You asked the Plan to pre-approve lumbar sacral facet joint radiofrequency neurolysis. The Plan denied your 
request. The Plan says the facet joint interventions do not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 lumbar sacral facet joint radiofrequency 
neurolysis. Our reviewer says that lumbar sacral facet joint radiofrequency neurolysis is not medically necessary. Our physician reviewer found this exceeds utilization criteria. Therefore, the request is considered 
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 lumbar sacral facet joint radiofrequency neurolysis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar sacral facet joint radiofrequency 
neurolysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visual field examination (92083), scanning computerized 
ophthalmic diagnostic imaging (92133), and outpatient office visit (99214) provided on February 21, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the visual field examination, scanning computerized ophthalmic diagnostic 
imaging, and outpatient office visit. You say that no referral is needed for an office visit. The Plan denied your 
request. The Plan says the treating provider is not a network provider with the Plan. The Plan also says that 
these services are not urgent or emergent, nor were they approved in advance. 
 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 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 the visual field examination (92083), scanning 
computerized ophthalmic diagnostic imaging (92133), and outpatient office visit (99214) provided on February 
21, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC). 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover duplicate or redundant durable medical equipment such as 
oxygen device when the second item performs the same function as the one currently provided. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necesary. Our physician reviewer found you are on 
home supplemental oxygen at 5L/minute. The requested device is not capable of delivering more than 
4L/minute. Medicare requires ambulatory oximetry using an oxygen conserving device to show the patient is 
able to maintain adequate SpO2 on 4 L/min or less, and this is not found in the record.  There is no 
documentation in the medical records of a need for a POC. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (POC).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee is medically stable with no new and acute medical problems and does not 
need PM&R physician supervision 3 times per week (at a minimum) for the ongoing management of any active 
or acute exacerbations of chronic medical conditions. At the current functional level, the enrollee does not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The enrollee's rehab needs can be met safely and provided at 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 23, 2021. 
 You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 documentation shows that clinical utility of the testing provided has not been met. This means that the 
genetic test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services (88312, 88305) provided on 
January 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 the surgical pathology services (88312, 88305) 
provided on January 11, 2022 by an out-of-network (OON) provider.