Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this 
case. The record shows that the Plan made multiple attempts to secure medical records, without success. 
Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this 
information, we decided that Medicare rules for coverage of Trivisc have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Trivisc.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 10, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on December 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cane (E0100) to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the mobility equipment. You say that you want to continue using the same 
durable medical equipment (DME) supplier. The Plan denied your request. The Plan says you meet criteria for 
medical necessity, but the requested provider is out-of-network. The Plan says there are in-network providers 
available that offer the same services.  
 
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 network providers 
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 
a cane (E0100) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4305-GY billed for date of service August 30, 2021. 
 
You asked the Plan to pay for code A4305-GY. You say that you have supplied all documentation required for 
this claim to be paid. The Plan denied your request. The Plan says this code is non-covered as billed. The Plan 
must follow Medicare rules. Medicare rules say that the GY modifier is used when suppliers want to indicate 
that the item or supply is statutorily noncovered or is not a Medicare benefit.  Claims submitted using the GY 
modifier are automatically denied.  You billed code A4305 with the GY modifier, meaning that this code is not 
covered. Therefore, we decided that the Plan does not have to pay for code A4305-GY billed for date of service 
August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 11, 2022 billed with 
codes 81292, 81294, 81295, 81297, 81298, and 81317. 
 
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 
February 11, 2022 billed with codes 81292, 81294, 81295, 81297, 81298, and 81317.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled nursing or therapy services. 
 
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 pre-approve SNF services. Our physician reviewer 
found that the enrollee is at a minimal assist level for sitting and standing up, and at a maximal assist for 
returning to bed. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2016. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on March 16, 2016.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 81479 is not supported in the medical record. Specifically, the services 
must be billed with the date of service the specimen was collected. The records show that the specimens were 
collected on January 24, 2022, and February 21, 2022. This means that the claim was billed with the incorrect 
date of service. 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 lab services provided on March 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that additional trips are required for your 
dialysis treatment. The Plan denied your request. The Plan says you have used 52 one-way trips for the year 
2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 52 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy (49654) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the laparoscopy. You say that the services should be covered as you 
disagree with the charges and the services are medically necessary. The Plan denied your request. The Plan 
says the services denied correctly as the same level of care can be provided by out-of-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 network providers 
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 
a laparoscopy (49654) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this would benefit you a lot. The Plan 
denied your request. The Plan says you do not meet the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose 
testing at least four times per day or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM).
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 wound vac cannot be managed at a lower 
level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
LTACH services do not meet the requirements for approval. 
 
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 that the enrollee appears to be stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion surgery with enhancing substance. 
 
You asked the Plan to pre-approve spine surgery. You say that the enrollee has failed other treatment options 
and has radiating pain. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because some bone-fusion enhancing substances have not been shown to be helpful. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no instability, fracture, or lesion. Fusion is not needed for lumbar disc herniation and 
arthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spinal fusion surgery with enhancing substance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vasectomy procedure (55250). 
 
You asked the Plan to pre-approve a vasectomy. You say that the requested procedure is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested procedure 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that elective hysterectomy, tubal ligation, and 
vasectomy are not covered if the primary indication for these procedures is sterilization. 
 
We looked at the file and Medicare rules. In this case, the medical records do not support that the primary 
indication for the requested procedure is other than sterilization. Based on this information, we decided that 
Medicare rules for coverage of a vasectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vasectomy procedure (55250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) 
coded as E0651. 
 
You asked the Plan to pre-approve the PCD. You say that a court case has indicated that the detailed 
measurements required by the LCD are in conflict with the National Coverage Determination. As such, this 
cannot be used to deny this request. The Plan denied your request. The Plan says the LCD remains in effect and 
must be adhered to at this time. As such, the denial of coverage is correct. 
 The Plan follows Medicare rules. Medicare rules say that a PCD may be covered when there is documented 
persistence of lymphedema despite a four-week trial of conservative treatment. 
 
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 PCD. Our reviewer says that the 
documentation does not support that the criteria for the requested PCD have been met. Our physician reviewer 
found the provided records do not document detailed measurements over time confirming the persistence of the 
lymphedema despite conservative treatments. 
 
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 PCD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device (PCD) coded as E0651.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve separate payment for procedure code A9270. 
 You asked the Plan to pre-approve procedure code A9270. You say that the Plan approved a replacement 
rollator walker with seat attachment and denied the brakes. Please approve the brakes. The Plan denied your 
request. The Plan says payment for code A9270 is bundled into payment for code E0143. 
 
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 A9270 
is a column II code to approved column I code E0143. 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 pre-approve separate payment for procedure code A9270.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 pre-approve 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 based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
that services in the home with home health care or in a long-term care facility on a part time basis are not 
appropriate in this case. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three wheelchair with two or more power 
options. 
 
You asked the Plan to pre-approve a group three wheelchair with two or more power options. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. The rules say that a Group three power wheelchair with power options 
are only covered for certain indications. 
 
The documentation does not support that the enrollee has a medical need in the home for drive wheel 
suspension (group three suspension), the enrollee required intermittent catheterization, the enrollee needs to lie 
backwards due to spasticity, or that the enrollee needs pressure relief. The enrollee does not meet criteria for 
the requested group three power wheelchair with power options. Therefore, we decided that the Plan does not 
have to pre-approve a group three wheelchair with two or more power options.