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

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is necessary for your condition. The 
Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck. 
 
You asked the Plan to pre-approve an MRI of the neck. The Plan denied your request. The Plan says the 
requested MRI is not reasonable and necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the neck. Our physician 
reviewer found the enrollee has lumbar pain with radiculopathy. The record does not document any symptoms 
related to the cervical spine or document any neurologic abnormalities relatable to the cervical spine. Our 
reviewer found that the requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that 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 an MRI of the neck have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor. 
 You asked the Plan to pre-approve the Dexcom continuous glucose monitor. You say that this device is 
medically necessary. The Plan denied your request. The Plan says only Freestyle brand continuous glucose 
monitors are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested continuous glucose monitor is not the plan preferred 
brand. No records were provided showing that the plan-preferred brand would be unsafe or ineffective for the 
enrollee. Based on this information, we decided that Medicare rules for coverage of the Dexcom continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nitro Euro-Style rollator walker. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical necessity for this specific brand. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome. 
 
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 walker. Our reviewer says that the 
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan has approved a standard walker. There is no medical necessity for this brand with a back 
rest. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Nitro Euro-Style rollator walker.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the correct CT scan for lung cancer screening would be a low dose CT scan of the chest. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that there are no 
medical records submitted. A history of "heavy smoking history" is insufficient for this request. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery (procedure code 21089) provided to the enrollee 
on March 21, 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 there is a more appropriate code to use in this case. 
 
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 21089 is "Unlisted maxillofacial prosthetic procedure." 
 
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 procedure does not include a 
maxillofacial prosthetic procedure. The documentation shows a "mouth-opening and tongue depressing 
radiation stent." In this case, a more appropriate radiology code should have been reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for oral surgery (procedure code 21089) provided to the enrollee on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure machine. 
 
You asked the Plan to pre-approve the machine. You say that this is medically necessary to keep your blood 
pressure down. The Plan denied your request. The Plan says this is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure machine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the Medicare coverage criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that in this case you are not within the age range of 50-77 years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home blood draws/home venipuncture. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have any documented skilled nursing needs, such as IVS, complex wound care, new ostomy, or new tube feeds. 
Lab draws alone are not an indication for home health skilled nursing services. You do not have documented 
skilled therapy needs. The requested services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home blood draws/home venipuncture.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88341 and 88342 billed for date of 
service March 30, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360, 88341 and 88342. You say that the billed charges are 
separate, distinct, and valid. The Plan denied your request. The Plan says code 88360 is included in the facility 
payment and is not separately payable. The Plan also says payment for codes 88341 and 88342 is bundled into 
payment for code 88360. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88360. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88360 have not been met.  
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88341 
and 88342 are column II codes to column I code 88360. 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 for 
procedure codes 88341 and 88342.  
 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 88360, 88341 and 88342 billed 
for date of service March 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection procedure; radioactive tracer for identification of 
sentinel node provided to the enrollee on June 13, 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 the code cannot be verified. 
 
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 38792 is "Injection procedure; radioactive tracer for 
identification of sentinel node." 
 
 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 operative report describes one 
sentinal node left breast. In this case it is inappropriate to report CPT 38792 and CPT  38900 for the 
identification of the same sentinel node. Therefore, modifier -59 cannot be verified. 
 
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 an injection procedure; radioactive tracer for identification of sentinel node provided to the 
enrollee on June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31505 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 31505. You say that the procedure was medically necessary. The 
Plan denied your request. The Plan says payment for code 31505 is bundled into payment for code 31500. 
 
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 31505 
is a column II code to column I code 31500 with a modifier indicator of 0. The column II code is therefore not payable. 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 31505 billed for date of service May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that the enrollee tests her blood sugar 4 times 
per day and would benefit from the use of a CGM. The Plan denied your request. The Plan says there is no 
evidence of 3 or more injections of insulin per day. 
 
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 administrations. The records show that the enrollee injects insulin only once per day at 
bedtime. Based on this information, we decided that Medicare rules for coverage of the requested CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan did not provide enough evidence based on Medicare 
criteria to support the denial of payment for these services. Therefore, we decided that the Plan has to pay for 
the laboratory services provided on July 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 
billed for date of service January 26, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381. You say that the 
testing should not be bundled with the hospital encounter. The Plan denied your request. The Plan says this 
code is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377, and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 billed for date 
of service January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
spacer at L3-4, in this case, is 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 1, 
2022.