Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) (77014, 
G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested IMRT is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered palliative radiation to the thoracic spine. IMRT for bone 
metastases is uncommonly needed for the palliative treatment. For this case, there is no dosimetric rationale for 
IMRT or explanation for why IMRT would be needed over 2D or 3D radiation. IMRT can be considered 
medically necessary (even for palliation and/or non-standard indications) when justified by quantitative dose 
measures when the dose-volume exposure of critical structures in unacceptable without IMRT. For this case, 
the volume is somewhat more complex than a case where just 1-2 levels of spine would be treated such that 3D 
radiation is plausibly needed over 2D radiation. However, the need for IMRT is not justified based upon 
quantifiable dosimetric measures or a plausible rationale. The ASTRO model policy emphasizes the need to 
support IMRT with dosimetry; this would be of particular importance for clinical scenarios for which IMRT is 
not considered standard. The decision is unfavorable for this case as IMRT would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT) (77014, G6002, G6015).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4595) provided on October 2, 2022.  
You asked the Plan to pay for the supplies. You say that you would like to appeal this denial. The Plan denied 
your request. The Plan says the provider signature date is missing on medical necessity page of initial 
correspondence. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Specifically, the documentation submitted does not include a valid 
signature from the persons responsible for the care of the beneficiary. The record shows that the physician 
order does not have a valid signature date. Therefore, we decided that the Plan does not have to pay for the 
electrodes (A4595) provided on October 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
September 22, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
  The items at issue in this appeal were for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for pneumatic compression devices (E0675, E0673) provided on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with procedure code 0241U for 
date of service December 22, 2022. 
 
You asked the Plan to pay for the laboratory testing billed with procedure code 0241U. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
billed with procedure code 0241U have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory testing billed with procedure code 0241U for date of service December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 28, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items are not covered in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (0241U) provided on December 21, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was necessary and is supported as 
billed. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0241U) 
provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right wrist hand orthosis (L3916) provided on December 
2, 2022. 
 
You asked the Plan to pay for the orthosis. You say that you would like to appeal this denial. The Plan denied 
your request. The Plan says the provided documentation does not sufficiently support the billed supply code. 
 
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 the supplies provided in this case. Specifically, there 
was not a physician order included in the case file. 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 right wrist hand orthosis (L3916) provided on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that you have a prolonged history of chronic pain. 
You say that you have been to physical therapy, an orthopedist, and pain management with no relief. You also 
say that your pain management doctor suggested you get a TENS device to help your pain. The Plan denied 
your request. The Plan says the requested device is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for chronic low back pain (CLBP) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transcutaneous electrical nerve stimulator (TENS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 26, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit in 
this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 and the half leg appliance billed with code E0673 for August 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) billed with code E0675 and the half leg appliance billed with 
code E0673 for August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the 
abdomen or stomach area. 
 
You asked the Plan to pre-approve CTA of the abdomen. 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 CTA of the abdomen. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found during the encounter of March 27, 2023, there was no mention of evaluation of the 
lower extremity peripheral pulses on physical exam and there has been no Ankle-Brachial Index to determine if peripheral vascular disease is likely. Absent these 2 assessments the medical necessity of the requested CTA 
has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography angiography (CTA) of the abdomen or stomach area.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2042 billed for date of service August 1, 
2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure code T2042. You say that you disagree with the Plan's denial. 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 T2042 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2042 billed for date of service August 1, 2022, to August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the records do not show that the enrollee is on insulin. 
 
 
 
 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. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) rendered 
on July 12, 2022. 
 
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 Current Procedural Terminology (CPT) code 99306 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided medical records do 
not support medical decision making of high complexity. The records do not document an extensive number of 
diagnoses or management options, an extensive amount and complexity of data reviewed and high risk of 
complication. The provided records contain no assessment of what the hospital records, labs, electrocardiogram 
and abdominal/pelvic computed tomography scan showed and how the results would be used in the patient's 
care plan.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial nursing facility care (procedure code 99306) rendered on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If this enrollee has chronic carbon dioxide (CO2) retention, they may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service September 21, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says the medical records do not support the billing of code 99285, so it was 
appropriately down-coded to 99284. The records indicate that only moderate medical decision making was 
utilized. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. . 
 
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the member is a 57-year-old female with a medical 
history including chronic lung disease requiring home oxygen therapy, diabetes mellitus and hypertension who 
presented to the emergency department on on September 21, 2022, with cough and shortness of breath with 
previous COVID-19 exposure. She was medically stable at the time of presentation. She was evaluated for 
possible COVID-19 infection and any underlying pneumonia. The diagnostic tests were negative, and she was 
treated for a chronic obstructive pulmonary disease exacerbation with symptom improvement. The member 
was discharged home the same day. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that is it not safe to discharge the enrollee home and you 
are appealing with supporting records. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.