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

 
We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), 
expandable controller (E2377), harness for upgrade to expandable controller (E2313) and electronic connection 
between wheelchair controller and two or more power seating system motors, including all related electronics, 
indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
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 the DME have not been met. A power seat elevation feature 
(E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function 
of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered." 
E2377 Expandable Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys 
Electro Connect Btw 2 Sys are requested to control power tilt, recline and elevating leg rests through the 
joystick. E2377 Expandable Controller, E2313 Expandable Controller Harness cannot be approved. The 
electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller 
(E2377) and harness (E2313) cannot be covered. Although there are three approved power features on this 
wheelchair (power tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick. Documentation shows that the member is independent with self-feeding. Upper 
limb strength and function are adequate for the member to be able to control the power options using their own 
switches which are included in the allowance of these power options. Therefore, we decided that the Plan does 
not have to pre-approve power seat elevation system (CPT code E2300), expandable controller (E2377), 
harness for upgrade to expandable controller (E2313) and electronic connection between wheelchair controller 
and two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (22612). 
 
You asked the Plan to pre-approve posterior lumbar arthrodesis. You say that the enrollee has suffered from 
persistent radicular back pain/neurogenic claudication for a documented period of time. The enrollee has failed 
or not sustained long-term benefits from conservative treatment within the past 12 months. You have chosen to 
move forward with a minimally invasive spinal fusion procedure. The Plan denied your request. The Plan says 
the requested procedure is not indicated for the enrollee's condition. Medicare has chosen not to cover this 
procedure at this time. The Plan also says experimental and investigational procedures are not covered by 
Medicare. 
 
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 posterior lumbar arthrodesis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found lumbar x-rays show significant spondylosis and shelving of right lamina.  
The enrollee rates her pain as 9/10; sitting down and leaning forward improve pain symptoms and she has 
trouble standing for any length of time which interferes with ADLs and quality of life. The Minuteman is a 
minimally invasive, interspinous-interlaminar fusion device intended for the fixation and stabilization of the 
thoracic, lumbar, and sacral spine while awaiting bony fusion to occur The Minuteman is designed for 
attachment to the posterior non-cervical spine at the spinous processes through its bilateral locking plates, and 
it is intended for use with bone graft material placed within the device. Interspinous process fusion devices are 
proven and medically necessary when used in conjunction with any of the following procedures:  Open laminar 
and/or facet decortication and fusion, Autograft inter- and extra-spinous process decortication and fusion, and 
Interbody fusion of the same motion segment. Medicare does not have a National Coverage Determination for 
interlaminar lumbar instrumented fusion devices.  In this case, the requested the items/services at issue in this 
case 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 posterior lumbar arthrodesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an arthrodesis, posterior or posterolateral technique, single interspace; 
lumbar (22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bebtelovimab injection (M0222) provided on June 7, 
2022. 
 
You asked the Plan to pay for bebtelovimab. You say that effective January 1, 2022, Medicare Advantage plans 
are responsible for payment of COVID-19 vaccine and monoclonal antibody services. You also say that the 
service should be paid. The Plan denied your request. The Plan says the claim denied correctly. 
 The Plan must follow Medicare rules. Medicare rules say that the FDA has not authorized bebtelovimab for use 
in any United States region because it is not expected to neutralize Omicron sub-variants BQ.1 and BQ.1.1. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bebtelovimab have not been met. Therefore, we decided that the Plan does not have to pay for the 
bebtelovimab injection (M0222) provided on June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod disposable insulin pump system. 
 
You asked the Plan to pre-approve an Omnipod disposable insulin pump system. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of 
durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-
covered items. 
 
We looked at the file and Medicare rules. The requested item is a disposable drug delivery system and is not 
covered. Based on this information, we decided that Medicare rules for coverage of an Omnipod disposable 
insulin pump system have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
Omnipod disposable insulin pump system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at 
a lower level of care such as skilled nursing facility (SNF), home with home health services or home with 
outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E0973x2, E1007, E2377, E2311, E1028x2, K0040x2, E0955, E2313, E2361x2, E1012, E0978, E2609, E2617, 
E2340, E2342, E0956x2, E0954). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says you are a resident of a long-
term care facility. Per Medicare, equipment must be appropriate for use in the home. 
 
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 a group 3 power wheelchair and accessories is being requested for use in a long-term care 
facility or hospital. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair and accessories (K0861, E0973x2, E1007, E2377, E2311, E1028x2, K0040x2, E0955, E2313, 
E2361x2, E1012, E0978, E2609, E2617, E2340, E2342, E0956x2, E0954).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. 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 December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022, billed with 
codes 81120, 81121, 81210, 81292, 81295, 81298, 81317, 81301, and 81191. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 17, 2022, billed with codes 81120, 81121, 81210, 81292, 81295, 81298, 81317, 81301, and 81191.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 16, 2022 to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. 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 February 16, 2022 to 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve referral to an out-of-network (OON) comprehensive 
multidisciplinary sarcoidosis center. 
 You asked the Plan to pre-approve the requested OON referral. You say that your condition has not been well 
managed by your providers as they are not able to work together. You feel that being evaluated by a team of 
several specialists will allow your condition to be correctly evaluated and treated. The Plan denied your 
request. The Plan says there is not sufficient evidence to support the need for the requested level of 
multidisciplinary care at this time. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 requested OON referral. Our 
reviewer says that the requested OON referral to a comprehensive sarcoidosis center is not shown to be 
medically reasonable and necessary at this time. Our physician reviewer found the enrollee has a history of 
sarcoidosis diagnosed more than 30 years ago following a lung lobectomy. Currently, the enrollee is troubled 
with chronic pain, a foot fracture, and acid reflux symptoms. There are also diagnoses of psoriasis, psoriatic 
arthritis, and myasthenia gravis, controlled on treatment. The enrollee was hospitalized for pneumonia in May 
2022, and chest imaging revealed ground glass opacities that were new since February. The enrollee had 
swallowing problems at that time, suggesting the possibility of aspiration. A follow-up scan was ordered by her 
pulmonary doctor, but that result was not found in the record.   
 
There is no indication that any of the enrollee's current symptoms are due to active sarcoidosis. Recent 
laboratory testing has been normal. Chest imaging has shown unchanged calcification of mediastinal and hilar 
lymph nodes, consistent with past sarcoidosis, but there is no current lymphadenopathy. There is no evidence 
of extra-pulmonary involvement with sarcoidosis. It appears that all of the enrollee's medical needs are being 
met with the current providers. Referral to a comprehensive sarcoidosis center is not medically necessary at this 
time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested OON referral have not been met. Therefore, we decided that the 
Plan does not have to pre-approve referral to an out-of-network (OON) comprehensive multidisciplinary 
sarcoidosis center.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Eylea. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative, Avastin. 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. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services (11057, 11720, G0127) provided on July 
20, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 11057, 11720, & G0127 is not supported in the medical record. Specifically, the claim 
was not billed with a valid place of service based on the records provided. Based on this information, we 
decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that 
the Plan does not have to pay for podiatry services (11057, 11720, G0127) provided on July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 14301 and 15734) 
provided to the enrollee on October 14, 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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 14301: 
 
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 
 
CPT 15734: 
 
Muscle, myocutaneous, or fasciocutaneous flap; trunk  
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 in terms of CPT 14301, the 
medical records provided indicate a hernia repair was performed during the same operative session.  Per the 
Bulletin of the American College of Surgeons, CPT 14301 is a code that may not be reported with a hernia 
repair. The medical records do not include documentation to validate CPT 14301 82 59 was performed as a 
distinct, separate procedure, not related to to the primary procedure. In terms of CPT 15734, the medical 
records provided do not include sufficient documentation to validate a Muscle, myocutaneous, or 
fasciocutaneous flap; trunk was performed on October 14, 2021, therefore 15734 62 cannot be verified and no 
additional payment is allowed. 
 
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 surgical services (procedure codes 14301 and 15734) provided to the enrollee on October 14, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 12, 2022, 
to February 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. 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 February 12, 2022, to 
February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested items. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliances (E0667 and E0656).