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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories 
(E2361, E1028, E2377E2313, E1007, E2620, E2311E1012, E0955, E0953, E2607E1028x2). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the therapist clearly 
documents the need for both power tilt and power recline in the equipment justification section. The Plan 
denied your request. The Plan says you do not meet criteria for tilt and recline features and therefore do not 
meet criteria for the requested wheelchair. Documentation does not show that you are at high risk for 
development of skin ulcers. No self-catheterization or spasticity; you are on no anti-spasmodics. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you are Mod I to 
transfer and shower. You are able to shift weight, are not incontinent or at high risk for skin breakdown. 
Therefore, medical necessity criteria are not 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories (E2361, 
E1028, E2377E2313, E1007, E2620, E2311E1012, E0955, E0953, E2607E1028x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on 
October 19, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no face to face encounter or proof of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) supplies must 
be provided with a proof of delivery and a face-to-face encounter.  
 
The required documentation pertaining to the proof of delivery of these supplies and the face-to-face encounter. 
was not provided. 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 durable medical equipment provided 
to the enrollee on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that the enrollee's multiple active comorbidities and continues to 
require close medical supervision on an inpatient basis. Evaluating therapists document that the enrollee 
requires intense therapy; therefore, IRF criteria has been met and is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis eye drops. 
 
You asked the Plan to pre-approve the Restasis eye drops. You say that this is a necessary treatment. The Plan 
denied your request. The Plan says this self-administered medication is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis eye drops.  
 
Benefits for the Restasis eye drops may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 while the enrollee may benefit from additional multiple therapies, including physical 
and occupational therapy, the documentation does not reveal that the enrollee requires or can tolerate this 
therapy on an intensive IRF level. 
 
 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 portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. The enrollee has been on continuous positive airway pressure (CPAP) in the past, presumably for 
obstructive sleep apnea (OSA).  A diagnosis of chronic obstructive pulmonary disease (COPD) is listed in the 
hospital record, but there is no evidence to support this. There are no pulmonary function tests, the enrollee is a 
never-smoker, and is on no bronchodilators. There is no diagnosis of thoracic restrictive disease or generalized neuromuscular disease. The enrollee may benefit from CPAP or bilevel positive airway pressure (BiPAP) 
during sleep. But Medicare does not cover a home ventilator for obesity hypoventilation syndrome (OHS), or 
when used as 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
for your upcoming doctors appointments. The Plan denied your request. The Plan says additional trips would 
exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
fifty-one (51) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips 
are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips (A0120).
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 (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the requested sensor is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. 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 (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 2 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 2. You say that this should be paid for. 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 64493 and 64494 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 2 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 2 billed for date of service February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous recording video electroencephalogram 
(VEEG) provided on August 3, 2021. 
 
You asked the Plan to pay for the continuous VEEG. You say that this was medically indicated and should be 
paid. The Plan denied your request. The Plan says this is not considered 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 pay for the continuous VEEG. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member suffered a closed head injury which apparently resulted in a concussion. There was not documentation provided that there was readily any suspicion of seizures or a seizure disorder. In such a 
context, an extended EEG would have exceeded the member's clinical needs. It would not have been the most 
appropriate type of service which could have been provided to the member at that time (as there were no 
indications or diagnostic needs). In as much, this request would not have been medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continuous VEEG have not been met. Therefore, we decided that the Plan 
does not have to pay for the continuous recording video electroencephalogram (VEEG) provided on August 3, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan eye drops. 
 
You asked the Plan to pre-approve the Zioptan eye drops. You say that this is medically necessary. The Plan 
denied your request. The Plan says the self-administered eye drops are not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan eye drops.  
 
Benefits for the Zioptan eye drops may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDX-SCC testing provided to the enrollee on May 9, 2022. 
 
You asked the Plan to pay for the testing. You say that the requisition form confirms that the test was ordered 
by the patient's treating physician with the intent to use the test results to inform treatment decisions. The Plan 
denied your request. The Plan says that this testing is not considered standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that lab tests are covered if there is demonstration of 
clinical validity and utility.  
 
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 testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that DecisionDx-SCC demonstrates a high degree of analytical precision, yielding high concordance 
rates across multiple performance experiments, along with exhibiting robust technical reliability on clinical 
samples. 
 
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 testing have been met. Therefore, we decided that the Plan has to pay for the 
DecisionDX-SCC testing provided to the enrollee on May 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for JAK2, JAK2 V617F, MPL, and CALR genetic testing 
provided to the enrollee on March 23, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this 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 pay for the testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the review indicates that the enrollee had abnormal blood tests concerning for a 
myeloproliferative disease. The record sent by the provider indicates previous testing for the BCR-ABL 
mutation and the test result was positive. Medicare guidelines state that single-gene testing for JAK2, JAK2 
V617F, MPL and CALR is only covered when BCR/ABL mutation analysis was negative. The review has 
determined that the records do not support that the enrollee meets the criteria in LCD L35000 for the JAK2, 
JAK2 V617F, MPL, and CALR genetic testing. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for JAK2, JAK2 V617F, MPL, and CALR genetic testing provided to the enrollee on March 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable Negative Pressure Wound Therapy (NPWT) 
(97607). 
 
You asked the Plan to pre-approve disposable NPWT. You say that the therapy is medically necessary. The 
Plan denied your request. The Plan says the criteria is not met as the disposable NPWT device is not covered as 
durable medical equipment because they are disposable and do not meet the durability requirement and would 
only be covered in the home supplied by a home health care agency and followed by the home health care 
agency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We looked at the file and Medicare rules. Medicare rules show that disposable NPWT is not covered as durable 
medical equipment because they are disposable and would only be covered in the home supplied by a home 
health care agency. Based on this information, we decided that Medicare rules for coverage of disposable 
NPWT have not been met. Therefore, we decided that the Plan does not have to pre-approve disposable 
Negative Pressure Wound Therapy (NPWT) (97607).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Udenyca (CPT code Q5111). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found this enrollee has a greater than 20% risk of neutropenic fever with the use of carboplatin and pemetrexed 
given age greater than 65 and prior chemotherapy. Undencya is indicated to minimize risk. The service is 
reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have been met. Therefore, we decided that the Plan has to pre-
approve Udenyca (CPT code Q5111).  
 
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 out of network services provided to the enrollee on April 11, 
2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network services provided to the enrollee on 
April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on September 20, 
2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says gene screening services such as these are not covered by Medicare. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in 
the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing 
provided to the enrollee on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee self-referred without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the outpatient diagnostic services require prior authorization. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 28, 
2021.