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

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971-LT, L1971-RT) provided 
from August 26, 2022, to August 27, 2022. 
 
You asked the Plan to pay for the orthotics. You say that the delivery confirmation indicates that the items were 
delivered to the enrollee's address. You also say that medical necessity was documented. The Plan denied your 
request. The Plan says the records do not indicate that the enrollee was treated for foot pain or referred for a 
foot brace. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order for a right foot orthotic, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the ankle foot orthosis (L1971-LT, L1971-RT) provided from August 26, 2022, to August 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
(87481, 87798, 87801) provided on November 19, 2021. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says PCR testing is not indicated as the following are appropriate 
means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 pay for a fungal infection PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to 
perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific. 
It is unclear as to why this enrollees right hallux toenail needed to undergo PCR testing when other less 
expensive and efficacious lab tests are available. Therefore, the requested PCR testing of this enrollees right 
hallux toenail was 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 fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel (87481, 87798, 87801) 
provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you are requesting reconsideration 
because records support the medical necessity. The enrollee has not been getting relief and is in severe pain. 
The Plan denied your request. The Plan says the spinal cord stimulator trial requested does not meet the 
requirements for approval. The request is not medically necessary because records do not show that the 
enrollee has been evaluated by a surgeon for surgical options. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. The enrollee is noted to have had physical 
therapy; however, this was noted to be in 2014. There have been no more documented recent physical therapy 
course failures. Additionally, it is not clearly documented the type and dates of the series of injections for the 
lumbar spine. The current documentation does not corroborate that this is a late/last resort in this clinical 
scenario. Therefore, the enrollee does not meet criteria for approval of the requested stimulator and is not 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous implantation of neurostimulator electrode array, epidural (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L3960) provided on October 7, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The enrollee was contacted directly by the 
DME supplier, the provided physician order is not valid. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for an orthosis (L3960) provided on October 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. 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 a CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy techniques (97140) provided on August 17, 
2022. 
 
You asked the Plan to pay for manual therapy techniques. You say that the services at issue were a medical 
necessity for you. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy techniques (97140) provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that you need this test to re-evaluate the enrollee's mitral 
regurgitation. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a TTE. Our reviewer says that the 
requested TTE is considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation indicates the enrollee has a history of mitral regurgitation. The reviewer found that an 
updated echocardiogram would be medically necessary to correlate the severity of probably asymptomatic 
mitral regurgitation, left ventricle (LV) size, and systolic function is clinically indicated. 
 
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 TTE have been met. Therefore, we decided that the Plan has to pre-approve a 
transthoracic echocardiography (TTE) (93306).  
 
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 urine polymerase chain reaction (PCR) panel (87640, 
87798, 87481, 87653) provided on September 28, 2021. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare 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 panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87640, 87798, 87481, 87653) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95938, 95939, 95955 rendered on November 24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that experimental or investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee underwent resection of an intracranial mass. It has become a standard of 
care to perform neuromonitoring during such services in order to assess neurological function during the 
procedures. Such services have demonstrated an improvement in outcomes and a reduction in post-operative 
complications. Furthermore, they can also guide intraoperative treatment decisions. In as much the services 
under review would have met the Medicare definition of medical necessity. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 95938, 95939, 95955 rendered on November 24, 2021.  
 
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 a Fungal Infection PCR Panel coded as 87798 and 87481 
provided April 18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please find attached medical records for 
review and reconsideration. The Plan denied your request. The Plan says this service is considered to be 
experimental or investigational as PCR testing is not indicated as appropriate means to verify fungal infection. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for a Fungal Infection PCR Panel coded as 87798 and 87481 provided April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TEN urinary tract infection (UTI) panel provided on 
October 20, 2022. 
 
You asked the Plan to pay for the TEN UTI panel. You say that this is a medically necessary, Medicare-
covered test. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing requires FDA approval or registration 
with MolDX and a TA to demonstrate compliance with the LCD policy. 
 
We looked at the file and Medicare rules. In this case the requested testing is not FDA approved nor does it 
have an approved TA on file. Based on this information, we decided that Medicare rules for coverage of the 
TEN UTI panel have not been met. Therefore, we decided that the Plan does not have to pay for the TEN 
urinary tract infection (UTI) panel provided on October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable to be 
transferred to an LTACH level of care at this time. You say that the enrollee is too medically complex for a 
lower level of care and will require extensive rehabilitative therapies to regain their strength. The Plan denied 
your request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be 
provided in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170). 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable benefit for 
this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.     
We looked at your request, the records in the case file, and the Plans rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Specifically, your 
request submitted to the Plan was for 57 additional miles for each trip, a total of 107 miles. However, the Plan 
contract provides coverage for 50 miles of driving distance only for each trip. Your request exceeds the 
allowable transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine mileage, per trip (A0170).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on May 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have submitted medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 
70100), a radiologic examination, chest (CPT 71045), diagnostic radiology procedures of the head and neck 
(CPT 70310), a swallowing function x-ray (CPT 74230), an upper gastrointestinal tract x-ray (CPT 74240), and 
an established patient office or other outpatient visit (CPT 99214) provided on October 18, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100-26), a radiologic 
examination, chest (CPT 71045), diagnostic radiology procedures of the head and neck (CPT 70310), a 
swallowing function x-ray (CPT 74230), an upper gastrointestinal tract x-ray (CPT 74240), and an established 
patient office or other outpatient visit (CPT 99214). You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were performed at a nursing home (via mobile 
van/portable x-ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100-26), a radiologic examination, chest 
(CPT 71045), diagnostic radiology procedures of the head and neck (CPT 70310), a swallowing function x-ray 
(CPT 74230), an upper gastrointestinal tract x-ray (CPT 74240), and an established patient office or other 
outpatient visit (CPT 99214) have not been met. Therefore, we decided that the Plan does not have to pay for a 
neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a radiologic examination, chest (CPT 71045), 
diagnostic radiology procedures of the head and neck (CPT 70310), a swallowing function x-ray (CPT 74230), 
an upper gastrointestinal tract x-ray (CPT 74240), and an established patient office or other outpatient visit 
(CPT 99214) provided on October 18, 2022.