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

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0651). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a four week trial of conservative therapy demonstrating failed response to treatment is 
required. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a detailed trial and failure of four weeks of conservative therapy is not adequately described in the 
available medical records. As stated in the Local Coverage Determination (LCD): Pneumatic Compression 
Devices (L33829): "At a minimum, re-assessments conducted for a trial must include detailed measurements, 
obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion 
of the various trials and therapy, with bilateral comparisons where appropriate." The provided records do not 
document this required level of detail. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compression device (E0651).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care (CPT code 99292) provided on September 8, 
2021. 
 
You asked the Plan to pay for procedure code 99292. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 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, we have confirmed that code 99292 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care (CPT code 99292) provided on September 8, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says 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 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 continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed wing air transport (A0430) provided on March 15, 
2022. 
 
You asked the Plan to pay for the fixed wing air transport. You say that this transportation was medically 
necessary. The Plan denied your request. The Plan says transportation from another country to the United 
States is not a covered benefit under Medicare. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the fixed wing air transport. Our reviewer 
says that the fixed wing air transport was not medically necessary. Our physician reviewer found the 
documentation did support that you suffered from an illness or injury that contraindicated transportation by any 
means other than ambulance. The documentation did not support that your condition was such that the time 
needed to transport you by ground, or the instability of transportation by ground, posed a threat to your survival 
or seriously endangered your health. Our reviewer also found that the documentation did not support that the 
transferring hospital did not have adequate facilities to provide the medical services that you 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 fixed wing air transport have not been met. Therefore, we decided that the 
Plan does not have to pay for the fixed wing air transport (A0430) provided on March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan. 
 
You asked the Plan to pre-approve a duplex scan. You say that you submitted clinical documents for 
reconsideration. The Plan denied your request. The Plan says no medical need is shown as to why the enrollee 
cannot get these services from an in-network provider. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan had contract providers located 
within reasonable distance and travel time from the enrollees home who could have provided a duplex scan. 
Under Medicare rules, this means that contract providers were accessible to the enrollee. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 18, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing is necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the claim did not include all the 
documentation to process the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. Molecular diagnostics tests require a DX-Z code. The claim information 
does not show that this code was billed as required. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab testing services provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 17, 2022. 
 
You asked the Plan to pay for the physician's office visit services. You say that the enrollee was referred by a 
provider to this physician and the services should be covered. The Plan denied your request. The Plan says the 
member's benefit states that prior authorization is required for doctors office visits. 
 
The Plan contract covers Physician/Practitioner services, including doctors office visits. The Plan says that 
doctors office visits requires prior authorization 
 
We looked at the file and the Plans rules. The file shows that the physicians office visit requires prior 
authorization and no authorization was obtained. Based on this information, we decided that the Plans rules for 
coverage of the physician's services have not been met. Therefore, we decided that the Plan does not have to 
pay for physician's office visit services provided on March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the requested IRF care does not meet the Medicare coverage 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 that you are medically stable and do not need a physical medicine and rehabilitation 
physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs identified or documented. At the current functional mobility, you do 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. An IRF admission 
is not medically necessary based lack of medical complexity and acute rehabilitation nursing needs. The 
documentation does not support the medical necessity for admission to an IRF. While you may benefit from 
continued physical therapy and occupational therapy, your rehabilitation needs can be safely provided in a 
lower intensity and alternate setting such as in a skilled nursing facility or in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33825). 
 
You asked the Plan to pre-approve the implantable cardiac loop recorder (ILR). You say that you are appealing 
an appeal for authorization request for procedure code 33285. Please review attached clinical information The 
Plan denied your request. The Plan says the requested implantable cardiac loop recorder does not meet the 
requirements for approval. 
 
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 implantable cardiac loop recorder 
(ILR). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested authorization for 
placement of an ILR is medically necessary. While the enrollee has a history of atrial flutter, there is no 
documentation provided to suggest a history of unexplained syncope or any other apparent indication for an 
ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 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 the implantable cardiac loop recorder (ILR) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (33825).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the control nasal hemorrhage, anterior (30903) billed on 
October 15, 2021. 
 
  You asked the Plan to pay for the control nasal hemorrhage, anterior (30903). You say that the denied CPT 
code constitutes a separate procedure from a previously paid surgical procedure and is not considered a 
component of that procedure. You say that this is not a mutually exclusive code pair and CPT code 30903-51-
59 should be reconsidered for payment. The Plan denied your request. The Plan says CPT codes 30903 and 
30905 shall not be reported separately. 
 
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, we have confirmed that code 30903 is a column II code to column I code 30905; however, 30903 
was billed with a modifier.  
 
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 control nasal hemorrhage, anterior (30903). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the medical records describe multiple nasal hemorrhage control sessions during the emergency 
department visit and only one same-side hemorrhage-control code should be reported. 
 
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 control nasal hemorrhage, anterior (30903) have not been met. Therefore, 
we decided that the Plan does not have to pay for the control nasal hemorrhage, anterior (30903) billed on 
October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis of prostate tumor tissue (81551) provided 
on April 6, 2022. 
 
You asked the Plan to pay for the gene analysis of prostate tumor tissue (81551). You say that the test was 
requested directly from the treating physician who makes the professional determination of diagnosis and 
medical necessity. You say that the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says the claim did not include the required DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code identifier must be 
entered adjacent to the CPT code when reporting a MolDX service.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gene analysis of prostate tumor tissue (81551) have not been met. Specifically, the DEX Z-
Code identifier was not billed on the claim. Therefore, we decided that the Plan does not have to pay for the 
gene analysis of prostate tumor tissue (81551) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you are not able to prick your fingers due 
to no meat on bones and no feeling. The Plan denied your request. The Plan says Medical criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplemental eyewear to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve out-of-network eyeglasses. You say that you can get eyeglasses for a lower 
cost from out-of-network providers, and you cannot afford the amount left on the in-network prices after 
insurance pays their portion. The Plan denied your request. The Plan says Out-of-network services are only 
covered in certain limited circumstances. The requested services are not urgent or emergent and can be 
provided in-network. There are thirteen available in-network providers who can provide the necessary services. 
 
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 
supplemental eyewear 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 a special stain including interpretation and report for Group I 
for microorganisms (88312) and a special stain including interpretation and report for Group II (88313) 
provided on July 14, 2021. 
 You asked the Plan to pay for a special stain including interpretation and report for Group I for microorganisms 
(88312) and a special stain including interpretation and report for Group II (88313). You say that this was a 
medical necessity. The Plan denied your request. The Plan says services are not meeting the criteria per Local 
Coverage Determination (LCD) L36234. 
 
The Plan follows Medicare rules. Medicare rules say that ordering certain special stains or IHC stains is not 
reasonable or 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 pay for a special stain including interpretation and 
report for Group I for microorganisms (88312) and a special stain including interpretation and report for Group 
II (88313). Our reviewer says that this does not meet the criteria for coverage. Our physician reviewer found 
there was no specific clinical rationale for the obtained studies. Our physician reviewer also found that the 
items/services at issue in this care were 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 a special stain including interpretation and report for Group I for 
microorganisms (88312) and a special stain including interpretation and report for Group II (88313) have not 
been met. Therefore, we decided that the Plan does not have to pay for a special stain including interpretation 
and report for Group I for microorganisms (88312) and a special stain including interpretation and report for 
Group II (88313) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the frames (V2020) and progressive lenses (V2781) 
provided May 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the frames and progressive lenses. You say that you do not agree with the 
denial. The Plan denied your request. The Plan says the eyewear is not covered because it was provided OON 
without prior authorization. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan may cover these services from an OON provider when prior authorization is obtained. 
 
We looked at the file and the Plan's rules. In this case the eyewear was purchased from an OON provider. Prior 
authorization was not requested. Based on this information, we decided that the Plan's rules for coverage of the 
frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pre-
approve the frames (V2020) and progressive lenses (V2781) provided May 26, 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 special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you 
qualify for the special supplemental benefits based on your medical condition. The Plan denied your request. 
The Plan says the criteria for coverage of these benefits have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that they may choose to offer some benefits to 
enrollees in addition to the covered Medicare Part A and Part B benefits. The Plan contract also says that they 
provide special supplemental benefits for the chronically ill. The benefit indicates that the enrollee must have 
one or more chronic conditions that is life threatening or significantly limits health or function, be at high risk 
for hospitalization, and require intensive care coordination.  
 
We looked at the file and Medicare rules. In this case, your provider has indicated that you do not have a risk 
for hospitalization and do not require intensive care coordination. Based on this information, we decided that 
Medicare rules for coverage of special supplemental benefits for the chronically ill have not been met. 
Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill.