Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87801) provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes, and not a 
single unit of one code as required by LCA A58710. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab services (87801) provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Assist device (L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says this device does not meet criteria for coverage since this device is considered 
experimental and investigational. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term 
use. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MyoPro 2 Motion G Assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that the claim was partially paid. The Plan 
denied your request. The Plan says payment for code 99214 is bundled into payment for code 96372. 
 
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 99214 is a column II code to column I code 96372. The code at issue 
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 
99214 billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested ventilator is not being used for 
positive airway pressure (PAP) or bi-level PAP therapy. You say that the enrollee has tried and failed all other 
therapies and the requested ventilator is needed due to the severity of the enrollee's disease. The Plan denied 
your request. The Plan says there does not appear to be any attempt to treat the enrollee first with a continuous 
PAP (CPAP) or bi-level PAP (BiPAP). The Plan says that the requested ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient has severe chronic obstructive pulmonary disease (COPD) with a recent exacerbation requiring hospitalization.  The enrollee's Arterial Blood Gas (ABG) when acutely ill was 
consistent with acute on chronic hypercarbic respiratory failure.  There is a strong suspicion of obstructive 
sleep apnea (OSA.)  However, there is no documentation of chronic carbon dioxide (CO2) retention with an 
ABG done while stable.  The enrollee has not been tried on BiPAP with average volume assured pressure 
support (AVAPS) as an outpatient and has not failed BiPAP as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endoscopic revision of sleeve gastrectomy. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there are not enough studies to show that revision weight loss surgery is safe and 
effective. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure endoscopic revision of gastric sleeve is not a standard treatment for 
morbid obesity. It has not been studied in a prospective or randomized controlled fashion with long term 
outcomes data showing that it is effective and durable. The requested treatment is investigational at this time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the endoscopic revision of sleeve gastrectomy.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Supartz (J7321). 
 
You asked the Plan to pre-approve Supartz. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that step-therapy rules for the requested drug have not 
been met. 
 
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. Specifically, the Plan did not provide a copy of the EOC or ANOC for the 2022 
benefit year to document that step-therapy requirements have been appropriately disclosed as mandated in the 
Medicare rules. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's 
denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-
approve treatment with Supartz (J7321).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the varicose vein laser ablation (37765, 36475, 36479) 
 You asked the Plan to pre-approve the varicose vein laser ablation. You say that you are in a lot of pain and 
would like to have this procedure approved. The Plan denied your request. The Plan says the Medicare rules 
have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the varicose vein laser ablation. Our 
physician reviewer found there is no documentation that you have lifestyle limitations due to your varicose 
veins. It is documented that you are already status post ligation or ablation of your great saphenous vein 
bilaterally with reflux noted in the calves only. Before and after pictures are documented to have been taken, 
but it is not described before and after what. The providers recommendation is compression stockings for a 
period of three (3) months. This time has not elapsed.  
 
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 varicose vein laser ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the varicose vein laser ablation (37765, 36475, 36479)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on June 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was 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  all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Plan outreach to the primary physician determined that the testing 
was not ordered by the treating physician. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing (81479) provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) testing provided 
on May 20, 2022, billed with codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was not medically necessary and was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR 
(polymerase chain reaction) testing provided on May 20, 2022, billed with codes 87481, 87500, 87640, 87641, 
87651, 87653, and 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 recent notes describe the enrollee with persistent delirium and requiring additional 
intravenous antibiotics and dialysis. The enrollee appears to be improving with the current treatment but is still 
somewhat unstable and should only require short term additional acute care services that can safely be provided 
at the current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not 
medically necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous 
at this time.  
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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 20, 
2021, through December 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says 
Medicare criteria for inpatient hospitalization have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on December 20, 2021, through 
December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically 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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for derangement of other medial meniscus due to old 
tear or injury of the left knee. The enrollee presented with left knee pain. She has a catching sensation. The 
exam reveals a range of motion of 0-125. There is pain with terminal extension and flexion. No gross 
instability is noted with Lachman exam. Varus and valgus are intact. McMurrays is positive. However, the 
diagnostic imaging studies (including x-rays) corroborate osteoarthritis in the left knee. The examinations 
provided did not corroborate significant mechanical symptoms. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. 
 There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the enrollee does not meet criteria for the requested 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 knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88360) provided on February 18, 2022. 
 
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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, this code has a professional 
component / technical component indicator of 1. The services were billed with place of service 22 (outpatient 
hospital). The required 26 modifier was not billed. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (88360) provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (power tilt and power recline) and accessories (K0861, E2359, E2373, E1028, E2377, E2313, E1007, 
E2620, E2311, E0955, K0108, E1012, E0956, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial and believe the power wheelchair is medically necessary. The Plan denied your request. The Plan says 
you do not have a medical need for the multiple power options included with the requested power wheelchair. 
Per Medicare rules, the requested power wheelchair is medically necessary when a person has a need for power 
tilt and power recline. The notes do not show that you have medical need for these power options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power wheelchair with multiple 
power options and accessories. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found provided records do not support that you are high risk for skin breakdown (you are able to stand 
from a seated position), have a history of pressure ulcer(s) or have had skin flap surgery. Records do not 
document you perform bladder self-catheterization and are unable to transfer independently or that you have 
increased muscle tone or spasticity. Therefore, the multiple power options (power tilt and power recline) and 
upgraded electronics (expandable controller, harness, and electronics) do not meet Medicare criteria for 
necessity. Based on the medical records provided, you appear to meet criteria for a group 3 power wheelchair 
but not the multiple power options and upgraded electronics. As the wheelchair base does not meet criteria for 
coverage, the requested accessories are not covered. 
 
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 power wheelchair with multiple power options and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
multiple power options (power tilt and power recline) and accessories (K0861, E2359, E2373, E1028, E2377, 
E2313, E1007, E2620, E2311, E0955, K0108, E1012, E0956, E2607).