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

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational for the enrollee's 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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. In addition, provided records report left upper extremity spasticity and a left shoulder 
subluxation which may be contraindications to use of the device.  
 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you were never told that you needed a referral 
to see this provider. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
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 requested 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 an outpatient visit provided on April 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941). 
 
You asked the Plan to pre-approve chiropractic manipulative treatment. You say that you have major pain from 
sciatica, with a lot of pain in the left hip down to your leg, making it hard to walk. The Plan denied your 
request. The Plan says chiropractic manipulative treatment is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic manipulative treatment Our 
reviewer says that the elements of the coverage criteria are not satisfied and  the requested service is not 
recommended. Our physician reviewer found that the record indicates that you have spinal stenosis with leg 
pain, heaviness and/or weakness with walking. Our physician reviewer also found that the records provided do 
not document the presence of subluxation shown by x-ray or physical exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic manipulative treatment (98941).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81162, 81317, 81203, 81300, 81323, 81351, 
81307, and 81319 billed for date of service June 23, 2021. 
 You asked the Plan to pay for procedure code 81162, 81317, 81203, 81300, 81323, 81351, 81307, and 81319. 
You say that you disagree with the denial. The Plan denied your request. The Plan says payment for codes 
81162, 81317, 81203, 81300, 81323, 81351, 81307, and 81319 is bundled into payment for code 81317. 
 
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 codes 
81162, 81317, 81203, 81300, 81323, 81351, 81307, and 81319 are column II codes to column I code 81317. 
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 81162, 81317, 81203, 81300, 81323, 81351, 81307, and 81319 billed for date of service June 
23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
rendered on October 30, 2021. 
 
You asked the Plan to pay for these services. You say that your original CPAP was recalled. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers equipment only when it is reasonable and 
necessary. If equipment serves the same purpose as equipment already available to an enrollee, it is not 
considered reasonable and necessary. 
 
You requested a new machine due to a provider recall. However, there is no indication that your current 
equipment was not working or that you were not being provided loaner equipment by the provider or warrantor 
while yours was being repaired due to the recall. The Plan is only required to intercede and pay for replacement 
equipment from another provider when the current equipment provider is not able to loan you equipment or fix 
your current equipment within a reasonable amount of time. The Plan instructed you to wait for communication 
and instructions on how to proceed from the provider. It is also noted that you purchased an upgraded So Clean 
machine because your current equipment was too hard to clean properly. You did not follow your Plan rules or 
the vendor return rules when you chose to purchase new equipment. You did not purchase the same equipment. 
Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) 
device rendered on October 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service July 15, 
2021. 
 
You asked the Plan to pay for procedure code 99024. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99024 is considered bundled and not separately payable. 
 
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 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump for a lower limb prosthesis. 
 
You asked the Plan to pre-approve the requested pump. You say that the system will help prevent errors in 
improper sock combinations being applied. The Plan denied your request. The Plan says there are not enough 
studies to show the vacuum socket is safe and effective for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
The file shows that a Willow Wood Limb Logic VASS system was requested. 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 pump.  Our physician reviewer found that the requested vacuum pump exceeds the enrollees medical needs and is not 
proven superior to a standard socket. Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. Per documentation, the physician note does not discuss the Willow Wood Logic VASS system. 
The literature reviewed indicates that further research is needed with clinical trials that recruit larger sample 
sizes and report long-term outcome data for the requested vacuum suspension system. Therefore, the request 
does not meet Medicares medically necessary criteria.  
 
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 pump have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum pump for a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
29, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 9, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the testing is excluded from Medicare coverage. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that pharmacogenetics hereditary cardiovascular testing was provided. Medications should be 
provided based on the presence of a diagnosis and should be adjusted based on a patient's response to the 
medication. It is not necessary to do genetic testing to provide or adjust medications. Screening services such as 
pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are 
not a Medicare benefit and are not covered. Therefore, we decided that the Plan does not have to pay for the lab 
testing provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the 
enrollee on January 6, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (procedure code 99100) provided to the enrollee on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the left upper extremity, 
provided on March 31, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item.  
 
 
  The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. Therefore, we decided that the Plan 
does not have to pay for a wrist-hand orthosis (L3916) for the left upper extremity, provided on March 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the diagnosis determines the optimal treatment 
pathway. The Plan denied your request. The Plan says the services could be provided by an in-network 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under 
certain medical indications. 
 
We looked at the file and the rules. In this case, there are no pathology reports or records from the treating 
physician to show that the coverage criteria for the testing have been met. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert or alarm device, not otherwise classified 
(A9280). 
 
You asked the Plan to pre-approve a life alert device. You say that you feel like you should be approved for the 
life alert system as you are at risk for falling and you are all alone in your home. You have fallen previously 
and injured your leg from hip to foot and you now use a walker or cane to get around. The Plan denied your 
request. The Plan says the requested device is not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alert or alarm device, not otherwise classified (A9280).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary to treat the enrollee's 
Type 2 diabetes mellitus. The Plan denied your request. The Plan says that this is not covered under 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 Trulicity for the enrollee.  
 
Benefits for this drug 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: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0483) provided on February 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 the services (G0483) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on January 31, 
2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for that HCPCS/CPT code will be denied. 
 
 
  We looked at the file and Medicare rules. In this case, CPT code 99233 has an MUE of 1. The Plan has paid for 
one unit of 99233. No further units of 99233 are payable. Based on this information, we decided that Medicare 
rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (99233) provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 97010 is considered bundled and not separately payable. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 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 Gel-One. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Durolane, Monovisc or Synvisc-One before they will approve the requested drug. The 
requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternatives. 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 alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gel-One (J7326).