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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that though the 
enrollee does not have lymphedema extending into chest, trunk or abdomen, the enrollee has tried other 
measures for six months, well over the four-week trial required. Therefore, this service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651 and no lymphedema extending into chest, trunk or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0657).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has left knee pain. The documentation does not support that the enrollee has tried and failed 
Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support that 
Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation doesnt support that the 
enrollee would meet criteria for admission to an acute inpatient rehabilitation 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on August 22, 
2022. 
 You asked the Plan to pay for hospital care. You say that this service is supported as billed. The Plan denied 
your request. The Plan says this service is not supported as billed, as the record shows that the enrollee was 
outpatient status at the time of services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services rendered to a patient who is a registered inpatient or an outpatient of a hospital. In 
these cases, the correct POS code - regardless of where the face-to-face service occurs - is that of the 
appropriate inpatient POS code or appropriate outpatient POS code. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed with 
POS code 21 (inpatient hospital). However, the medical record indicates that the enrollee was outpatient 
observation status on the date in question, and there is an outpatient hospital claim for this enrollee for this 
date. Based on this information, we decided that Medicare rules for coverage of hospital care have not been 
met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on 
August 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement (36247). 
 
You asked the Plan to pre-approve selective catheter placement. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 selective catheter placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the record indicates that the enrollee has prostatic hypertrophy 
with lower urinary tract symptoms. The record indicates that prostatic artery embolization is planned. There is 
insufficient literature to support the safety and efficacy of the requested service for the enrollee's condition. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of selective catheter placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve selective catheter placement (36247).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 99212. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99212 is bundled into payment for code 20600. 
 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 99212 
is a column II code to column I code 20600. 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 procedure code 99212 billed for date of service May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable wound suction devices (A9270, A9272) and 
related supplies. 
 
You asked the Plan to pre-approve disposable wound suction devices. You say that you were hospitalized for 
vascular surgery and a PICO wound vac was placed. PICO treatment continued in rehab, and you were 
removed from PICO, but you are not healing like you should. Your provider requested these supplies to be 
continued at home for the best possible course of treatment for you to achieve full healing of these deep 
wounds. The Plan denied your request. The Plan says the requested disposable wound suction devices are not a 
covered benefit with your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCA confirms that the requested devices are not a covered 
benefit with your plan because they do not meet the DME benefit durability requirement. Based on this 
information, we decided that Medicare rules for coverage of disposable wound suction devices have not been 
met. Therefore, we decided that the Plan does not have to pre-approve disposable wound suction devices 
(A9270, A9272) and related supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has unilateral primary osteoarthritis of the right knee. The documentation does not support 
that the enrollee has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The 
documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely 
be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the requested Eylea is medically necessary. The Plan 
denied your request. The Plan says the requested Eylea is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Eylea. Our reviewer says that the 
requested Eylea is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of Serous detachment of retinal pigment epithelium. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital observation discharge management services 
provided on July 1, 2022. 
 
You asked the Plan to pay for the observation discharge services. You say that the records support that this 
service was provided as billed. The Plan denied your request. The Plan says that this cannot be paid because the 
Plan did not receive claims with codes from ranges 99218-99220 or 99224-99226. 
 
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 clearly supported its denial rationale in this case. The Plan's 
main argument is that because no claims were received for the observation care provided on the first two days 
of the admission, the observation discharge services cannot be paid. However, it is unclear whether the Plan 
has been billed for those services by another physician. Whether or not another provider may have billed for 
the services on the prior dates, the records do support that the enrollee was in an observation stay from June 29, 
2022, through July 1, 2022, and that the physician at issue in this case provided the discharge management 
services. Therefore, we decided that the Plan has to pay for the outpatient hospital observation discharge 
management services provided on July 1, 2022.  
 
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: 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 you are currently in the hospital and are requesting 
the appeal to be expedited. The Plan denied your request. The Plan says medically necessary care may be 
provided safely in a different level of care. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
medically necessary care may be provided safely in a different level of care.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the denture. You say that you disagree with the denial of the mandibular 
denture. The Plan denied your request. The Plan says that your benefit for a complete mandibular denture has 
already been exhausted. 
 
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 did not provide the correct Evidence of Coverage (EOC) that was in 
effect at the time the initial authorization request was made. Without the correct EOC we are unable to verify 
the frequency limitation for the requested service. Therefore, we decided that the Plan has to pre-approve a 
complete mandibular denture (D5120).  
 
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 genetic testing provided on September 23, 2021, billed 
with codes 81286, 81404, 81405, 81406, 81407 and 81439. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 23, 2021, billed with codes 81286, 81404, 81405, 81406, 81407 and 81439.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve a replacement oxygen concentrator. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment can 
in no case be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered 
to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for an oxygen 
concentrator received by you in November 2018. Therefore, the requested replacement is for an item that has 
not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for 
coverage of a replacement oxygen concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a replacement oxygen concentrator (E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9343 billed for date of service May 4, 2022, 
to May 12, 2022. 
 
You asked the Plan to pay for procedure code S9343. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9343 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9343 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9343 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9343 billed for date of service May 4, 2022, to May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the 
neck. 
 
You asked the Plan to pre-approve the CTA scan. You say that the CTA is medically necessary. The Plan 
denied your request. The Plan says medical therapy is recommended. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CTA scan. Our reviewer says that 
the CTA scan of the neck is not medically necessary. Our physician reviewer found that the record indicates 
that the enrollee has vertigo. The record includes a carotid artery duple that demonstrates no stenosis in the left 
carotid artery and 1-49% on the right. The provided records do not indicate the medical necessity or 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography angiography (CTA) scan of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the transport chair, adult size, patient weight 
capacity up to and including 300 pounds (E1038) purchased August 6, 2022. 
 
You asked the Plan to reimburse you for the transport chair. You say that please reconsider as the cost is far 
less than the Plan would have paid renting a full-sized chair and will meet your needs. The Plan denied your 
request. The Plan says the item was purchased from a provider who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the transport chair, adult size, 
patient weight capacity up to and including 300 pounds (E1038) purchased August 6, 2022.