Persius/hicric huggingface dataset:
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 a CGM. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says an IRF is not medically necessary, 
and the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM sensor. You say that the requested CGM is necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for 
the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections 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 Dexcom 
G6 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 continuous glucose monitor (CGM) sensor (K0553).
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 enrollee requires daily visits from a physiatrist to 
manage their multi-faceted recovery, and to can maximize their recovery in an IRF which specialize in 
traumatic injuries. The Plan denied your request. The Plan says an IRF is not medically necessary, and the 
enrollee's needs can be met at an alternate level of care. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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. Medically necessary care can be provided in a different level 
of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81002 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 81002. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 81002 is bundled into 
payment for code G0483. 
 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 81002 
is a column II code to column I code G0483. 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 81002 billed for date of service April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultralightweight wheelchair (K0005). 
 
You asked the Plan to pre-approve the wheelchair. You say that the brakes are too tight on your current 
wheelchair and your hands are very sore. You need the ultralight weight. The Plan denied your request. The 
Plan says enrollee does not meet the medically necessary criteria. 
 
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 the wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is documentation that this enrollee has a personal mobility deficit that impairs 
participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in 
customary locations within the home. There is no documentation that the enrollees mobility deficit cannot be helped by the use of a walker and there is no documentation that the enrollee can safely operate the requested 
ultralightweight wheelchair. In addition, the provided records do not document that the enrollee is a full-time 
manual wheelchair user. The enrollee requires individualized fitting and adjustments for one or more features 
such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ultralightweight wheelchair (K0005).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (01830-QK-QS-P3) provided to the
enrollee on September 3, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that this claim is a duplicate of another claim
that was paid.
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same
day to the same patient by the same physician or more than one physician in the same specialty in the same
group, only provide should report these services. Based on the documentation provided, this claim cannot be
paid as billed due to the physician group relationship between the two providers. Medicare billing criteria were
not met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (01830-QK-QSP3)
provided to the enrollee on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code G0463. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code G0463 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0463 is statutorily excluded. Based on this information, we decided that Medicare rules for coverage of procedure code G0463 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0463 billed for date of service January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements 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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 the requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 you were admitted for total hip replacement for aseptic necrosis of the hip. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ 
neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy 
number amplifications, and gene rearrangements (0242U) provided April 12, 2022. 
 
You asked the Plan to pay for the Guardant360 CDx test. You say that the Guardant360 CDx test is FDA 
approved and covered by Medicare under a National Coverage Determination. Since the enrollee is covered by 
a Medicare Advantage Plan, the Plan is required to cover and pay for services that are covered for Part B 
beneficiaries. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the members terminal condition until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 25, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the targeted genomic 
sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation 
for sequence variants, gene copy number amplifications, and gene rearrangements (0242U) provided April 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monthly rental charge for a negative pressure wound 
therapy (NPWT) pump for the month beginning February 22, 2022. 
 
You asked the Plan to pay for the monthly rental charge for an NPWT pump. You say that this was medically 
necessary and ordered by the provider for a non-healing wound. The Plan denied your request. The Plan says 
the enrollee returned the pump as of January 17, 2022, meaning that no payment can be made for a monthly 
rental charge after that date. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of NPWT treatment will cease when 
either the treating physician determines it is no longer needed, or when it is no longer being used regardless of 
whether the physician ordered this. 
 
We looked at the file and Medicare rules. As of January 17, 2022, the enrollee reported no longer having the 
NPWT pump. As it was no longer being used as of this rental date, payment cannot be made for this date. 
Based on this information, we decided that Medicare rules for coverage of the monthly rental charge for an NPWT pump have not been met. Therefore, we decided that the Plan does not have to pay for the monthly 
rental charge for a negative pressure wound therapy (NPWT) pump for the month beginning February 22, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin (J9035). 
 
You asked the Plan to pre-approve Avastin. You say that the enrollee needs this drug added to their current 
chemotherapy regimen that is in place. The Plan denied your request. The Plan says the enrollee has not tried 
and failed the preferred drugs, Zirabev and Mvasi. 
 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 Avastin. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no documentation 
provided indicating that the plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. 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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin (J9035).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caris gene panel testing. 
 
You asked the Plan to pre-approve the testing services. The Plan denied your request. The Plan says the testing 
is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications. 
 
  
 We looked at the file and Medicare rules. The records do not show that the requested testing is FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Caris gene panel testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the LTACH admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. The reviewer 
found that there are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 4, 
2022 to May 5, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled nursing services or skilled physical, occupational or speech therapy. The Plan also says that the enrollee 
received established oxygen and oral medications. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not qualify for SNF coverage during this period. The enrollee 
did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. 
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs could, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 4, 2022 to May 5, 2022.