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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that you have not checked 
your sugar levels and you need the requested CGM. You also say the prior CGM is not effective for you, and 
you need it changed. The Plan denied your request. The Plan says you do not have the benefit for a Freestyle 
Libre 2 CGM because information received from your provider states you received a CGM on 5/12/2022, less 
than 5 years ago. 
 
 
 
 
 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 records show that you received a CGM monitor on May 12, 
2022, less than 5 years ago. Therefore, you have exhausted your benefits for the requested CGM and supplies. 
Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
2 continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342, 88360 and 88381) billed 
for date of service January 19, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says Medicare rules for billing have not bee met in this case as 
the professional interpretation of a diagnostic test must be separately billed with modifier 26 by the interpreting 
physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341, 88342, 88360 and 88381 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology 
services (88341, 88342, 88360 and 88381) billed for date of service January 19, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member without complex rehab needs. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the enrollee nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ogivri (CPT code Q5114). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says that the cancer specialists request to change the frequency of dosing to every two 
(2) weeks is not based on an anticipated medical benefit, but rather convenience. The Plan states this is 
considered an investigational way to dose this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the requested use of Ogivri FDA-approved for the enrollees diagnosis of breast cancer, but not in the 
interval requested. The use is supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal if it is given every two (2) weeks with Folfox for another 
indication. The documentation supports that the requested drug is safe and effective and otherwise reasonable 
and necessary for this enrollee. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Ogivri (CPT code Q5114).  
 
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 genetic testing (81455) provided on April 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT code 81455 is not supported in the medical record. Specifically, the date of service billed 
does not match the date of service the specimen was collected (March 15, 2022). Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for genetic testing (81455) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and abutment supported 
crown (D6059) tooth #28 and #29. 
 
You asked the Plan to pre-approve custom abutment (D6057) and abutment supported crown (D6059) tooth 
#28 and #29. You say that the enrollee has problems with eating and chewing food due to tooth loss. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom abutment (D6057) and abutment supported crown (D6059) tooth #28 and #29.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of obinutuzumab in combination with Venetoclax 
injections (CPT code J9301). 
 
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 that there is not enough evidence found in the medical literature to 
show that more than six cycles of this medicine are effective for managing this condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the requested use of obinutuzumab is not FDA-approved for the enrollees diagnosis. The use is 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal and the treatment is for twelve (12) months. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve continuation of obinutuzumab in combination with Venetoclax injections (CPT code J9301).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve Myobloc. 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 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 Myobloc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no documentation that the Myobloc at issue in this case 
meets all Medicare criteria for safe and effective.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myobloc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myobloc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81206, 81272, 81210, 81235) provided 
January 6, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a 
diagnostic laboratory test is reasonable and necessary and covered nationally when the test has Food and Drug 
Administration (FDA) approval or clearance as a companion in vitro diagnostic; and, an FDA-approved or 
cleared indication for use in that patients cancer. 
 
We looked at the file and Medicare rules. The test was not FDA approved for the enrollee's condition at the 
time it was performed. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81206, 
81272, 81210, 81235) provided January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0202U) provided January 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that  The Plan denied your request. The Plan says 
medical records have not been provided for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services (0202U) provided 
January 21, 2021, have been met. Specifically, the claim was denied for medical necessity and the Plan made 
multiple requests for medical records. These medical records were not provided. Without this information, we are unable to determine that the criteria for coverage are met. Therefore, we decided that the Plan does not have 
to pay for the lab services (0202U) provided January 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 18, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were rendered based on the 
enrollee's medical condition. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81162, 81206, 81301, 81311) performed on 
October 13, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. Correct coding 
requires that when a panel code is ordered, it should be billed, rather than the individual gene codes. 
 
We looked at the file and Medicare rules. Multiple individual codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81162, 81206, 81301, 81311) 
performed on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81235, 81162) provided on March 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 lab services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the performed testing does not meet current guidelines. The enrollee does not have a greater than or 
equal to one close blood relative with breast cancer at age 50 or less, or ovarian, pancreatic, metastatic, 
intraductal/cribriform histology, or prostate cancer at any age; or does not have documented 3 total diagnoses 
of breast cancer in her and/or close blood relatives.  
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (81235, 81162) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient eye exam (92004), fundus photography with 
interpretation (92250), and a gonioscopy (92020), provided on April 1, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a new patient eye exam (92004), fundus photography with interpretation 
(92250), and a gonioscopy (92020). You say that you verified benefits online, and did not realize a referral was 
required. You also say that patient did not bring in a referral either. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says that they have determined that 
these services were not approved in advance.  
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 a new patient eye exam (92004), fundus 
photography with interpretation (92250), and a gonioscopy (92020), provided on April 1, 2022, 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 breg polar care wave cold compression therapy system 
(E0218). 
 
You asked the Plan to pre-approve a breg polar care wave cold compression therapy system. You say that you 
are having a total knee replacement and the requested item should be covered because you will need this 
equipment to recover from surgery. The Plan denied your request. The Plan says per Medicare guidelines, a 
fluid circulating cold pad with pump is specifically excluded from coverage as it is considered not reasonable 
and medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
 
 
 We looked at the file and Medicare rules. Specifically, a fluid circulating cold pad with pump is not a covered 
benefit with Medicare or your Plan. Based on this information, we decided that Medicare rules for coverage of 
a breg polar care wave cold compression therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a breg polar care wave cold compression therapy system (E0218).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 20, 2022.