Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health nurse services. 
 
You asked the Plan to pre-approve home health nurse services. You say that home health nurse services are 
medically necessary to help you put on compression stockings. The Plan denied your request. The Plan says the 
requested services do not require the specialized judgment, knowledge, and skills of a registered nurse or LPN. 
The service can be safely and effectively provided by a non-skilled person. 
 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 home health nurse services. Our 
reviewer says that home health nurse services are not medically necessary. Our physician reviewer found that 
based on the documentation provided, you do not have documented skilled nursing needs (i.e., IVs, complex 
wound care, new ostomy, new transfer factors).  As such, the requested home health nurse services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health nurse services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health nurse services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum pump (L5781), a multi-axial rotation unit (L5986), and 
a shank-foot system (L5987) for a lower limb prosthesis. 
 
You asked the Plan to pre-approve a vacuum pump, a multi-axial rotation unit, and a shank-foot system. You 
say that the requested items are a necessity for your care. The Plan denied your request. The Plan says that 
medical-necessity rules for the requested items have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the enrollees potential functional abilities. 
 
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 vacuum pump, a multi-axial rotation 
unit, and a shank-foot system. Our reviewer says that the requested items are medically reasonable and 
necessary in this case. Our physician reviewer found that you are documented as being a K3-level ambulator by 
both the provider and the Plan. You are having difficulty only due to an ill-fitting socket. The items coded 
L5987, L5986 and L5781 would be medically necessary since your current foot/ankle are listed as K2-level by 
vendor documentation. 
 
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 vacuum pump, a multi-axial rotation unit, and a shank-foot system have been 
met. Therefore, we decided that the Plan has to pre-approve a vacuum pump (L5781), a multi-axial rotation 
unit (L5986), and a shank-foot system (L5987) for a lower limb prosthesis.  
 
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: Favorable

 
We decided that the Plan has to waive the coinsurance for outpatient diagnostic tests provided on May 13, 
2022. 
 
You asked the Plan to waive the coinsurance for outpatient diagnostic tests. You say that you should not be 
responsible to pay this because the services were medically necessary. The Plan denied your request. The Plan 
says that the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for out-of-network diagnostic tests and 
procedures.  
 
The Plan says you must pay $266.65 for outpatient diagnostic tests. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for out-of-network diagnostic tests and procedures for 
diagnostic radiology. Therefore, we decided that the Plan has to waive the coinsurance for outpatient diagnostic 
tests provided on May 13, 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 the genetic testing provided on November 10, 2021 billed 
with codes 81238, 81220, 81226, 81335, 81227, 81230, 81355, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 10, 2021 billed with codes 81238, 81220, 81226, 81335, 81227, 81230, 81355, 81291, and 81240.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection (0232T). 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that you need this because of a 
scalp burn. The Plan denied your request. The Plan says that there is insufficient high-quality evidence to 
justify the use of platelet rich plasma for the treatment of any wounds. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT 0232T is not a covered code. 
 
The requested injection is coded with CPT 0232T. Therefore, we decided that the Plan does not have to pre-
approve a platelet rich plasma injection (0232T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014), and fundus photography 
(92250) provided on January 20, 2022. 
 You asked the Plan to pay for an eye examination, and fundus photography. You say that you thought the 
provider was in-network. The Plan denied your request. The Plan says services obtained out-of-network are not 
covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when services are obtained from a provider in the Plan's vision vendor 
network. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye examination, and fundus photography have not been met. Specifically, the services were 
obtained out-of-network and are not covered. Therefore, we decided that the Plan does not have to pay for an 
eye examination (92014), and fundus photography (92250) provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug test (80307) definitive drug test 
(G0481) provided on January 10, 2022 to January 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that being that you are a reference laboratory, 
you do not have face-to-face patient contact. Services were performed according to the request of the ordering 
physician. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 presumptive drug test (80307) definitive drug 
test (G0481) provided on January 10, 2022 to January 13, 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 the platelet-rich plasma injections (0232T) provided on 
March 30, 2022. 
 
You asked the Plan to pay for code 0232T. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that upon reconsideration, The Centers for Medicare 
and Medicaid Services (CMS) has determined that platelet-rich plasma (PRP) - an autologous blood-derived 
product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure 
wounds. 
 
 
 We looked at the file and Medicare rules. The file shows that the platelet rich plasma injections were provided 
to treat musculoskeletal injuries and/or joint conditions. Medicare excludes coverage of platelet rich plasma 
injections for this condition. Therefore, we decided that the Plan does not have to pay for the platelet-rich 
plasma injections (0232T) provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) 
includes all supplies and accessories (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM, supplies and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says you do 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 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 CGM, 
supplies and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM) includes all supplies and accessories (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee scooter represented by code E0118 and billed for date 
of service April 13, 2022. 
 
You asked the Plan to pay for the knee scooter. You say that your doctor advised you that you needed a knee 
scooter to assist in your recovery following surgery. You say that a representative from the Plan advised you 
that if you purchased a scooter on your own you would be reimbursed. You say that you needed the scooter to 
be able to perform the limited movement that you were allowed and to assist in recovery. The Plan denied your 
request. The Plan says there is no information showing that you could not have used alternative assistive 
devices such as crutches. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes represented by code E0118. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Therefore, we decided that the Plan does not have to pay for a 
knee scooter represented by code E0118 and billed for date of service April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner lift chair (A9270). 
 
You asked the Plan to pre-approve a recliner lift chair. You say that you suffer from polio in both legs and 
transitioning from sitting to standing is very difficult. You also say the recliner lift chair is made for fall risk 
patients and you live alone. The Plan denied your request. The Plan says recliner chairs are not covered, as they 
are considered convenience/comfort items, not primarily medical in nature. 
 
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 a recliner lift chair (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA), a procedure to treat pain 
by destroying the nerve tissue in the hip region using electric current (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are having very bad pain and you 
need this procedure. The Plan denied your request. The Plan says the request must be for a covered service. 
Sacral lateral nerve branch ablations to treat pain in the joint that connects the pelvis to the tailbone (sacroiliac 
joint) are not supported by research and not covered. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have tried pain medication, physical therapy, warm compresses/heat and muscle 
relaxers. You are doing better after a procedure and relays there is some minor discomfort and reports 60% 
relief. You are also s/p SI joint injection bilaterally and reported 90% relief, but report pain has returned since 
the injection. Your provider has recommended a sacroiliac joint radiofrequency ablation. Sacral lateral nerve 
branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain 
is considered experimental and investigational.  Radiofrequency ablation for denervation, whether performed 
using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA), a procedure to treat pain by destroying the nerve 
tissue in the hip region using electric current (64625).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 2, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 4, 
2021 to December 31, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service-only code and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 4, 2021 to December 31, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the service does not meet the criteria for the category under which 
it was billed. 
 
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. Review of the file shows that the Plan has denied this service due to "the criteria 
for the category under which it was billed". However, no other explanation/information on why this claim was 
denied was provided. This means the Plan did not substantiate their denial. Therefore, we decided that the Plan 
has to pay for the laboratory services provided on June 11, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor (CGM) 
transmitter kit. 
 
You asked the Plan to pre-approve Dexcom G6 CGM transmitter kit. You say that the requested supplies are 
medically necessary for your diagnosis. The Plan denied your request. The Plan says you do not meet 
authorization 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 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 Dexcom G6 
CGM transmitter kit have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Dexcom G6 continuous glucose monitor (CGM) transmitter kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial for 
admission to a long-term acute care hospital level of care. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements for admission. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.