Persius/hicric huggingface dataset:
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 the requested supplies are medically 
necessary due to type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the 
enrollee does not meet coverage criteria of the requested CGM and supplies. 
 
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, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results or have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. 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 September 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutch substitute (E0118) and miscellaneous durable 
medical equipment (E1399) purchased July 5, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that your foot surgery was on July 7, 
2022, and you purchased the knee scooter because you were told that you would be non-weight bearing for 8 
weeks. The knee scooter is your only means of moving about. The Plan denied your request. The Plan says the 
items was purchased from a provider that does not participating with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the crutch substitute (E0118) and 
miscellaneous durable medical equipment (E1399) purchased July 5, 2022.
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 the requested CGM is 
medically necessary due to type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The 
Plan says the enrollee does not meet coverage criteria for the requested CGM. 
 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daily ultrasound guidance for radiation therapy. 
 
You asked the Plan to pre-approve daily ultrasound guidance for radiation therapy. You say that the requested 
services are medically necessary as they provide an accurate assessment of the precise composition of the 
lesions and thus, result in more accurate treatment of the lesions. The Plan denied your request. The Plan says 
there is not enough medical evidence to show that the requested type of radiation treatment is effective to treat 
the enrollee's skin cancer. 
 
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 daily ultrasound guidance for radiation 
therapy. Our reviewer says that daily ultrasound guidance for radiation therapy is not considered medically 
reasonable and necessary in this case. Our physician reviewer found to bill for daily simple simulations and/or 
image-guided radiation therapy (IGRT) for a technology for which need has not been established by published 
data or supported by consensus guidelines is not necessary. Billing for daily IGRT or daily simulations would 
not be furnished in accordance with accepted standards of medical practice.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daily ultrasound guidance for radiation therapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve daily ultrasound guidance for radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that these tests should 
be included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. 
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the requested device is medically 
reasonable and necessary and is supported by the records provided. The Plan denied your request. The Plan 
says the clinical value and effectiveness of MyoPro orthotic device in the setting of unilateral left upper 
extremity impairment following a stroke have not been demonstrated in the peer-reviewed literature. 
 
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 a MyoPro orthotic device. Our reviewer 
says that a MyoPro orthotic device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's condition or in widespread use for this patient's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the longterm outcomes 
for this patient.  There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 5, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services (97116, 97530) provided on July 
29, 2022. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services should be resubmitted with the KX modifier in order to be 
processed for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the KX modifier should 
be used as a confirmation that services are medically necessary after the beneficiary has exceeded the KX 
modifier threshold of incurred expenses. If a claim is submitted without KX modifiers and the cap is exceeded, 
those services will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the record shows that the enrollee in question has 
exceeded the KX modifier threshold of incurred expenses, but the KX modifier was not used on the 
claims/services at issue. Therefore, we decided that the Plan does not have to pay for outpatient therapy 
services (97116, 97530) provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the anesthesia records are attached, and the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Monovisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Durolane, Euflexxa, Gel-One, Gel-Syn, GenVisc, Hyalgan, Hymovis, Orthovisc, Supartz FX, 
Sodium hyaluronate, Synvisc, Synvisc One, Triluron, TriVisc, or Visco-3. The documentation does not support 
that Durolane, Euflexxa, Gel-One, Gel-Syn, GenVisc, Hyalgan, Hymovis, Orthovisc, Supartz FX, Sodium 
hyaluronate, Synvisc, Synvisc One, Triluron, TriVisc, or Visco-3 would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L3916) provided on May 24, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the wrist orthosis was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided do not document any discussion of this item being needed with the provider 
or how it would be used. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis 
(L3916) provided on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that due to the low severity of the enrollee's condition and low complexity 
of presentation, it is not expected that the enrollee would require hospitalization that would likely cross 2 
midnights. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is a diagnosis of COPD, but 
there are no clinical data or pulmonary function tests to confirm or assess severity. There is no ABG, done 
while stable, to document chronic CO2 retention. If you do have severe COPD with chronic CO2 retention, you 
may benefit from BiPAP with AVAPS during sleep.  There is no documentation that this has been tried and 
failed as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid. 
 
You asked the Plan to pre-approve Synthroid. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the requested drug is self-administered and is not 
covered under Part B. The Plan says that they do not administer pharmacy benefits for the enrollee. 
 
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 Synthroid.  
 
Benefits for Synthroid 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple procedures on this 
date. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and were reported appropriately. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator with settings that could be 
delivered by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
for this enrollee with COPD is not covered. 
 
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 home ventilator. Our physician 
reviewer found claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).