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

 
We decided that the Plan does not have to pre-approve the portable gaseous oxygen system (E0431) and 
oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve the oxygen concentrator and portable gaseous oxygen system. You say that 
you are asking for an appeal of the decision to deny your request for authorization. The Plan denied your 
request. The Plan says the records do not support that the enrollee needs 02 during sleep and the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator and portable 
gaseous oxygen system Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the medical records do not show 
oxygenation data that indicates a need for oxygen. SpO2 was 93% and 98% on 2 occasions, presumably 
breathing room air. Medicare criteria for oxygen are not met. 
 
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 oxygen concentrator and portable gaseous oxygen system have been met. 
Therefore, we decided that the Plan does not have to pre-approve the portable gaseous oxygen system (E0431) 
and oxygen concentrator (E1390).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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 January 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on January 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on January 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 3 power wheelchair with a captains seat. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you need the group 3 power wheelchair. 
The Plan denied your request. The Plan says the requested Group 3 power wheelchair exceeds the enrollee's 
needs and is not reasonable and necessary, per Medicare criteria. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation is conflicting that the enrollee has a mobility deficit that impairs 
MRADLs in the home. The medical progress note on 12/14/21 states that the enrollee has an unremarkable gait 
with no assistive device. She has normal upper and lower motor strength and normal sensation. The 4/5/22 
seating evaluation is conflicting on MRADL deficits. Furthermore, the enrollee is on Memantadine for 
dementia per the medical progress note. There is no detailed cognitive evaluation supporting whether the 
enrollee can safely evaluate a power mobility device given her dementia. The records are conflicting that the 
enrollee has a mobility limitation due to a neurologic condition. There is no evidence of   myopathy, or 
congenital skeletal condition. The physician note on 2021 notes the enrollee had a TIA in 2019. The physician 
notes indicates normal motor and sensory strength. There documentation does not reveal deficits from polio, a 
CVA, or other neurologic condition. The Wheelchair evaluation notes a stroke with left sided weakness but this 
is not noted on the physician progress note. The requested Group 3 wheelchair exceeds the enrollees medical 
needs. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the group 3 power wheelchair with a captains seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility deficit that 
impairs the ability to complete mobility-related activities of daily living (MRADLs) in the home. The 
documentation notes that the mobility deficit can be helped by the use of a manual wheelchair. She may be able 
to safely operate the power scooter, but the documentation does not reveal that it is medically necessary. The 
power scooter is also being requested for use outside of the home. The services are not reasonable or medically 
necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 19, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have chronic 
obstructive pulmonary disease (COPD) and were recently admitted to the hospital with pneumonia. A venous 
blood gas (VBG) test was consistent with acute respiratory failure. There is no arterial blood gas (ABG) study 
done while you were stable as an outpatient to establish chronic carbon dioxide (CO2) retnetion. The criteria 
for coverage are not met and the home ventilator is not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. At this time, the procedure is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the repairs up to the cost of replacement. We decided that the Plan 
does not have to pre-approve the cost of repairs beyond the cost of replacement.  
 
You asked the Plan to pre-approve the PWC repairs. You say that you have had a stroke and are unable to get 
around without the PWC. You feel these repairs are necessary for your condition. The Plan says that the cost of 
repairs, including prior repairs, will exceed the cost of replacement. Therefore, no repairs can be approved. 
 
 
 We decided that the Plan has to pre-approve the repairs up to the cost of replacement.  
 
The Plan follows Medicare rules. Medicare rules say that repairs to make equipment serviceable are covered up 
to the cost of replacement.  
 
In this case, the Plan indicated that the cost of replacement for this equipment would be $1825. The Plan attests 
that payment has been made only for $1080. The current repair estimate is $1926.20. Based on the Medicare 
rules, this means that repairs should be covered up to the cost of $745. Any cost beyond this amount are your 
responsibility. Therefore, we decided that the Plan has to pre-approve the repairs up to the cost of replacement.  
 
We also decided that the Plan does not have to pre-approve the cost of repairs beyond the cost of 
replacement. 
 
The Plan follows Medicare rules. Medicare rules say that while repairs to equipment are covered up to the cost 
of replacement during the five-year reasonable useful lifetime of equipment, no payment can be made for costs 
which exceed this replacement cost.  
 
The Plan does not have to approve payment beyond $745. Therefore, we decided that the Plan does not have to 
pre-approve the cost of repairs beyond the cost of replacement. 
 
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 pathology services provided on February 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says the code is inappropriate for the place 
of service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 85060 was billed with 22, a hospital outpatient place of service. No payment is 
recognized for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the pathology services provided on February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enterolysis services provided on March 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that the records support the procedure codes. The 
Plan denied your request. The Plan says the service is not separately reportable. 
 
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 44005 is a column II code to column I code 49561 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the enterolysis services 
provided on March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
  You asked the Plan to pre-approve Ocrevus. You say that you and the enrollee decided that they need a more 
aggressive therapy than their current Gilenya. You also say that Ocrevus was selected due to its efficacy, 
mechanism of action, and 6-month dosing schedule. The Plan denied your request. The Plan says the enrollee 
does not have any stated contraindications to the preferred products. The Plan also says that the enrollee has not 
tried any of the preferred agents, and a rationale was not provided for use of the non-preferred product for 
safety or efficacy. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ocrevus. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step one alternative. Our reviewer also found that the record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that you feel a trial of Dupixent is the next step in 
therapy for the enrollee. The Plan denied your request. The Plan says Dupixent is on the self-administered drug 
list and is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
December 10, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service).  
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 3. This means this is a technical component only code. The claim was 
billed incorrectly and therefore, not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation services coded 99153 provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81479 provided on July 20, 
2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not billed correctly. 
 
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 81479 is not supported in the medical record. Specifically, this code was billed with a 
GZ modifier. Claim lines with GZ modifier are automatically denied as non-covered services. Based on this 
information, we decided that Medicare rules for coverage of the laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81479 provided on 
July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 2, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says with the 
information we have, we cannot determine how the member came to the servicing provider, or whether the 
services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. 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 the lab services provided on May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service February 5, 
2022 to February 7, 2022. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99220. 
 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 99497 
is a column II code to column I code 99220. 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 99497 billed for date of service February 5, 2022 
to February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from February 7, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided from February 7, 2022, to 
February 14, 2022.