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

 
We decided that the Plan has to pre-approve the Q-logic Expandable Joystick. 
 
You asked the Plan to pre-approve the Q-logic Expandable Joystick. You say that the item is medically 
necessary. The Plan denied your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Q-logic Expandable Joystick. Our 
reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is non-ambulatory and requires a power wheelchair for mobility and 
performing her basic daily activities. She cannot perform pressure relief independently due to weakness and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. She also 
requires power elevating leg rests for positioning, The complexity of her seating and positioning needs 
necessitates a more complex group 3 power wheelchair base. The expandable joystick is necessary to operate 
the group 3 power wheelchair base and the power tilt and recline and power elevating leg rests via a joystick. 
 
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 Q-logic Expandable Joystick have been met. Therefore, we decided that the 
Plan has to pre-approve the Q-logic Expandable Joystick.  
 
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: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the injections provided on June 7, 2022, and 
September 10, 2022. We decided that the Plan does not have to waive the copayment for the nerve study 
provided on August 26, 2022.  
 
You asked the Plan to waive the cost share for the nerve conduction and injections. You say that these 
copayment amounts have changed and are too high. The Plan says that this cost sharing was charged correctly. 
 
 We decided that the Plan has to waive the coinsurance for the injections provided on June 7, 2022, and 
September 10, 2022.  
 
According to Medicare, a betamethasone acetate injection (code J0702) is considered a packaged code and is 
not separately payable. Code J0702 is also excluded from the physicians fee schedule. Therefore, we decided 
that the Plan has to waive the coinsurance for the injections provided on June 7, 2022, and September 10, 2022. 
 
We also decided that the Plan does not have to waive the copayment for the nerve study provided on 
August 26, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for other diagnostic procedures and tests, including a nerve study.  
 
You have been asked to pay a $95 copayment for the nerve study. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the nerve study provided on August 26, 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: 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 do not understand why this is now 
being denied. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
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 puse insulin 
with at least three daily injections. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography (CTA) scan of the pelvis. 
 
You asked the Plan to pre-approve the CTA scan. You say that the requested CTA is medically necessary. The 
Plan denied your request. The Plan says that the records show that the study requested will be done prior to a 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA scan. Our reviewer says that 
the CTA scan of the pelvis is medically necessary. Our physician reviewer found that the requesting urologist 
has provided ample evidence in published literature showing the efficacy of prostate artery embolization (PAE) 
as a treatment for benign prostatic hyperplasia (BPH) and the articles that was attached to support this view. In 
preparation for the procedure the CTA of the pelvis is reasonable and will provide a roadmap for the 
embolization procedure to follow. PAE is now a mainstream procedure for BPH, and the requested CTA of the 
pelvis should be approved. 
 
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 CTA scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography angiography (CTA) scan of the pelvis.  
 
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 a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve the CGM and relates supplies. You say that the CGM is medically necessary 
for the enrollee to monito their blood sugars. The Plan denied your request. The Plan says the Medicare criteria 
was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and relates supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
related supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the CGM is medically 
necessary for the enrollee to regulate their blood sugar levels. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic continuous glucose monitor (CGM) and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospitalist care provided from April 25, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for physician visits. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the records do not support the codes 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, typically 35 minutes are spent at the bedside and on the patients 
hospital floor or unit. 
 
We asked our coder 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 physician visits. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found there are no progress notes for the dates of service in question. 
There is no evidence that these procedures were performed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician visits have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospitalist care provided from April 25, 2022, to April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (eo), with adjustable position locking 
joint(s), prefabricated, off-the-shelf provided on October 13, 2022. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says the documentation submitted did not sufficiently support the billed supply code. 
 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 pay for the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation provided does not support the need for an elbow orthosis. The patient has 
a medical history of small cell lung cancer and elbow pain. There is limited clinical history regarding the 
patients elbow pain and no physical examination is provided, including elbow range of motion and joint 
stability. Without this documentation it cannot be determined if the requested elbow orthosis is medically 
appropriate and necessary. Therefore, the requested elbow orthosis was 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 the item have not been met. Therefore, we decided that the Plan does not have 
to pay for an elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf provided 
on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided on April 26, 2022, and 
April 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit". The CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
We asked our coder 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 the services. Our reviewer says that the use of code 99223 
and 99233 is not supported by the records provided. Our reviewer found that code 99223 requires a medically 
appropriate history and/or examination and high level of medical decision making. However, the medical 
records submitted did not support a a comprehensive examination and medical decision making of high 
complexity. Code 99233 a requires a medically appropriate history and/or examination and high level of 
medical decision making. However, the medical records submitted did not support an interval history and 
medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. 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 (99223, 99233) provided on April 26, 2022, and April 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found it is not clear that an adjustment to the 
patient's Venofer dose would not be more appropriate than giving the patient two different formulations of 
parenteral iron replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve the Life2000 ventilator. You say that you are requesting review of the denial 
of coverage for the Life2000 ventilator. This was prescribed to help manage the enrollee's complicated 
respiratory needs at home. The Plan denied your request. The Plan says ventilators used to provide continuous 
positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) therapy will be denied as not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 ventilator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicates that the enrollee has chronic respiratory failure from chronic 
obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage 
for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
 
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 Life2000 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the 
upper extremity; without contrast material(s) (73221). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says you do not meet criteria for coverage of the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have neck pain radiating to the shoulder after a motor vehicle accident. An MRI of the 
cervical spine has been approved. The record provided does not indicate the failure of conservative therapy of 
the shoulder. The requested service is not medically necessary and reasonable for the diagnosis and treatment 
of your clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI), of any joint of the upper extremity; without contrast 
material(s) (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 99358. You say that this claim should be paid. The Plan denied 
your request. The Plan says payment for code 99358 is bundled into payment for code 99305. 
 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 99358 
is a column II code to column I code 99305. 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 99358 billed for date of service August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and 
segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that the doctor 
has ordered the Bio compression brand lymphedema pump for this enrollee. You are the only supplier in the 
enrollee's geographical area that supplies this lymphedema pump. The Plan denied your request. The Plan says 
enrollees must receive medical services from an in-network provider. 
 
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 the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an 
out-of-network (OON) provider.