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

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667 x 2), segmental pneumatic appliance for use with pneumatic compressor, trunk 
(E0656) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that he DME is necessary. 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 DME. Our physician reviewer 
found the records do not show that you have lymphedema extending onto the chest, trunk and/or abdomen, and 
there is no documentation that you had a four- week trial of conservative therapy demonstrating failed response 
to treatment with an E0650 or E0651. The review has determined that the medical records provided did not 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667 x 2), 
segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and pneumatic compressor, 
segmental home model with calibrated gradient pressure (E0652).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you would like Ilumya to be prescribed to the enrollee 
for the treatment of moderate to severe plaque psoriasis. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Ilumya. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer also found that the elements of the coverage criteria are not 
satisfied, and 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac (SI) joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is not enough information in the medical journals to say that such 
procedure is proven for your condition. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has 
determined that the requested SI joint RFA 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac (SI) joint, with image guidance 
(ie, fluoroscopy or computed tomography) (64625).
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 May 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Urinary Tract Infection (UTI) panel billed with multiple 
procedure codes (including 87801) for date of service July 26, 2022. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary and was billed 
and submitted appropriately. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of UTI testing have not been met. Specifically, the records show that a single panel was ordered and 
performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for a Urinary Tract Infection (UTI) panel billed with multiple procedure codes (including 
87801) for date of service July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve wound care treatment to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
wound care treatment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx (81479) provided on December 8, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says SelectMDx in males with previous negative prostate biopsy who are being 
considered for repeat biopsy and is promising with evidence of some clinical utility to reduce unnecessary 
repeat prostate biopsies. The Plan states there was no documented result of prior prostate biopsy. The Plan 
states there was no documented significant interval increase in PSA level. 
 
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 laboratory service. Our physician 
reviewer found the enrollee does not have a history of prostate cancer or a prior prostate biopsy based on the 
provided documentation which is required to consider the SelectMDx urine testing according to the LCD for 
Medicare coverage. Therefore, the medical records provided do not meet these requirements.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for SelectMDx (81479) provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 87801. You say that these services were necessary and were 
billed and submitted appropriately. 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 procedure code 87801 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87801 billed 
for date of service August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rollator walker purchased June 4, 2021. 
 
You asked the Plan to pay for the rollator walker. You say that please reconsider your claim and reimburse you 
the $59.99 that you paid for the walker. The Plan denied your request. The Plan says the item was purchased 
from a provider that does not participate with Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the rollator walker purchased June 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 99233 is bundled into payment for code 99222. 
 
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 99233 
is a column II code to column I code 99222 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 99233 billed for date of service June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device (E0470) provided on May 22, 
2022. 
 
You asked the Plan to pay for the respiratory assist device. The Plan denied your request. The Plan says the 
claim was billed without the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the KX modifier must be added to code E0470.  
 
We looked at the file and Medicare rules. In this case, code E0470 was not billed with modifier KX as required by LCA A52467. Based on this information, we decided that Medicare rules for coverage of the respiratory 
assist device have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
assist device (E0470) provided on May 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair back cushion (E2617), 
headrest hardware (K0108), a wheel bumper (K0108), a cup holder (K0108) and an attendant control (E2331) 
for a power wheelchair. 
 
You asked the Plan to pre-approve a custom fabricated wheelchair back cushion, headrest hardware, a wheel 
bumper, a cup holder and an attendant control. You say that the requested items are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 custom fabricated wheelchair back 
cushion and headrest hardware. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is no report providing any 
information in support of a custom fabricated cushion as opposed to a prefabricated cushion. There is no 
information in support of a head 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 a custom fabricated wheelchair back cushion and headrest hardware have not 
been met. Furthermore, a wheel bumper and a cup holder do not serve a purpose that is primarily medical in 
nature. Finally, the record shows that the Plan has approved a beneficiary-operated drive control system. An 
attendant control is non-covered when provided in addition to a beneficiary-operated drive control system. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated wheelchair back cushion 
(E2617), headrest hardware (K0108), a wheel bumper (K0108), a cup holder (K0108) and an attendant control 
(E2331) for a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 4, 2022, to 
January 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 4, 2022, to 
January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac (SI) joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says radiofrequency neurolysis for SI joint pain is 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational because of the wide variation in efficacy 
reported in the literature. Therefore, the request is deemed not medically reasonable and 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac (SI) joint, with image guidance 
(ie, fluoroscopy or computed tomography) (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223.  
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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty, upper eyelid; with excessive skin 
weighting down lid (CPT code 15823). 
 
You asked the Plan to pre-approve the surgical services. You say that the surgical services are necessary. 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 surgical services. Our physician 
reviewer found the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage below. The documented MRD is 3.5mm bilaterally, and consistent with the photos provided. The 
visual field testing does not show improvement in visual field with taping (shows the opposite) and is not 
considered reliable.  
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve blepharoplasty, upper eyelid; with excessive skin weighting down lid (CPT code 
15823).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a SNF stay provided from June 1, 2022, to June 14, 
2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were getting ready to be released 
when you got COVID from them, so you had to stay in the room for 10 days. The Plan denied your request. 
The Plan says that the cost sharing was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not forward proof of any previous SNF admission. Without this 
information we are unable to determine if the cost sharing was applied correctly. Therefore, we decided that the 
Plan has to waive the copayment for a SNF stay provided from June 1, 2022, to June 14, 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.