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

 
We decided that the Plan does not have to pre-approve shoe lifts. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are necessary, and you need 
financial assistance in paying for the shoe lifts. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe lifts.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from April 27, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you received a denial of payment for 
self-administered drug you received during your short stay in the observation room. You say that the hospital should know that the drug was not covered. You also say that you should not have been given this. The Plan 
denied your request. The Plan says self-administered drugs are not covered under Medicare Part B. The Plan 
also says that they are not covered under the medical benefits of the plan. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting from April 27, 2022, to April 28, 2022.  
 
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infed 100MG/2ML vial (CPT code J1750). 
 
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 this request has exceeded the dosing frequency and/or duration of 
injections indicated by acceptable standards of medical practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 INFeD is FDA-approved for the treatment of patients with documented iron deficiency in whom oral 
administration is unsatisfactory or impossible. The documentation does not support that the requested drug is 
safe and effective and otherwise reasonable and necessary for this enrollee. The General Precertification 
Request in the case file states, "Requesting 6 visits of 1000 mg per dose." Each mL of INFeD contains the 
equivalent of 50 mg of elemental iron (as an iron dextran complex). The maximum daily dose of INFeD should 
not exceed 2 mL undiluted iron dextran. The case file does not support this request which exceeds the dosing specified on the product label. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Infed 100MG/2ML vial (CPT code J1750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the testing to 
be done out of medical necessity. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no 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 the laboratory services provided on April 12, 
2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 1, 2022.
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found you were recently hospitalized 
for surgery for a transfemoral amputation. It is not necessary that you receive the intensity of rehabilitation 
physician oversight provided in the acute inpatient rehabilitation setting. You do not require rehabilitation nursing for parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder management. 
While you could benefit from physician oversight and wound care after your amputation, this does not 
necessitate an intensive interdisciplinary approach provided in acute inpatient rehabilitation. More importantly 
it is not clear per the documentation that you can tolerate the intensity of therapies provided in acute inpatient 
rehabilitation. You require stand by assistance for bed mobility and minimal assistance for transfers. You 
require significant assistance for toileting and bathing. You have had a functional decline from your baseline 
level of function and require occupational and physical therapy, but it is not clear that you can participate in an 
intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. Therefore, the acute inpatient rehabilitation admission is not 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 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: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on February 21, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 8, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 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 an office visit provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing rendered on February 
7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
adenocarcinoma of the pancreas with metastases to the liver. FoundationOne Liquid CDx does not have Food 
and Drug Administration (FDA) approval or FDA clearance as a companion in vitro diagnostic, and an FDA-
approved or FDA-cleared indication for use in the enrollee's cancer. The testing was therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne Liquid CDx testing rendered on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the facility which indicates that these services are included in the dialysis rate. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 2 home health skilled nursing visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 2 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not 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 2 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31290 provided on 
April 1, 2022. 
 
You asked the Plan to pay for the nasal/sinus endoscopy services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 31290 is nasal/sinus endoscopy, surgical, with repair of 
cerebrospinal fluid leak; ethmoid region. 
 
We find that CPT code 31290 is not supported in the medical record. Specifically, this service was not billed 
with an appropriate anatomic modifier. Based on this information, we decided that Medicare rules for coverage 
of the nasal/sinus endoscopy services have not been met. Therefore, we decided that the Plan does not have to 
pay for the nasal/sinus endoscopy services coded 31290 provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office/outpatient visit provided on February 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office/outpatient visit. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 office/outpatient visit provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the excision of hyperplastic alveolar 
mucosa (99202, 41828) provided on April 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the excision of hyperplastic alveolar mucosa. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
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 office visit and the excision of hyperplastic 
alveolar mucosa (99202, 41828) provided on April 13, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast prosthesis and bra purchased on March 12, 2022. 
 
You asked the Plan to pay for the breast prosthesis and bra. You say that you believed this provider accepted 
Medicare. The Plan denied your request. The Plan says the enrollee used a non-Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the breast prosthesis and bra purchased 
on March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physician service. You say that the in-network provider is only able to 
get you in for an appointment once per month. You also say that you need to be seen on a weekly basis. The 
Plan denied your request. The Plan says there are equally qualified in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there is a 
network provider available who can provide the items/services at issue in this appeal. We found no exception 
that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not 
have to pre-approve an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 36247 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 36247 is selective catheter placement, arterial system; 
initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular 
family. 
 
We find that CPT code 36247 is not supported in the medical record. Specifically, there is no documentation of 
a selective catheter placement into the arterial system for the initial third order or more selective abdominal, 
pelvic, or lower extremity artery branch. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level, LT and RT 
(CPT code 64483 x2). 
 
You asked the Plan to pre-approve the injections. You say that the last injection was August 16, 2022, and this 
is scheduled for September 15, 2022. The Plan denied your request. The Plan says there is no documentation 
that there is at least 50% of sustained improvement in pain relief and/or improvement in function measured 
from baseline using the same scale for at least three (3) months. 
 
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 injections. Our physician reviewer 
found the initial transforaminal epidural steroid injection was done last month, on August 16, 2022. In addition, the requested epidural is in the same area as the previous injection and does not show a change in the technique 
or medication to be used. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level, LT and RT (CPT code 64483 x2).