Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. 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. 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 an MRI of the cervical spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found absent a red flag, the 
medical necessity of MRI of the cervical spine without a supervised 6-week trial of physical therapy has not 
been established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne Liquid CDx (F1CDx) testing (0239U) provided on 
March 12, 2021. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that this test is denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no reason for denial, and no citation or other 
evidence was provided to support their decision. Therefore, we decided that the Plan has to pay for 
FoundationOne Liquid CDx (F1CDx) testing (0239U) provided on March 12, 2021.  
 
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 durable medical equipment (DME) to be provided at the 
in-network benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the DME. You say that the provider must be a dentist and a DME supplier, 
per Medicare's policy. You also say that the in-network providers are not dentists. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 confirmed there are 
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 durable medical equipment (DME) to be provided at the in-network benefit level by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy treatment (97039) and the manual 
therapy (97140) provided from February 17, 2022, through April 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the physical therapy treatment (97039) and the manual therapy (97140) 
provided from February 17, 2022, through April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says a wig is not covered by Medicare or the Plan for your condition. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does offer a supplemental benefit which would 
provide coverage for a wig for members that experience hair loss due to treatment for cancer. The file shows that this is not the reason for the requested wig. Therefore, we decided that the Plan does not have to pre-
approve a wig.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 82043, 82570, 
83036, 84439, 84443 and 85025) 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 2, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 82043, 82570, 
83036, 84439, 84443 and 85025)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 25, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 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 the durable medical equipment 
provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99252 and 64425 billed for date of service 
October 3, 2022. 
 
You asked the Plan to pay for procedure codes 99252 and 64425. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
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 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99252 is not valid for Medicare purposes.  
 
Medicare guidelines also state that modifiers -LT and -RT are to be used to identify procedures, which can be 
performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be 
used whenever a procedure is performed on only one side. Hospitals use the appropriate -LT or -RT modifier to 
identify which of the paired organs was operated upon. In this case, the file shows that procedure code 64425 was 
not billed with an appropriate modifier.  
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99252 and 64425 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99252 and 
64425 billed for date of service October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. If the enrollee does have chronic carbon dioxide (CO2) retention, bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep may be of benefit. Medicare 
does not cover a home ventilator when used at settings that can be provided with 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator (K1018, K1019). 
 
You asked the Plan to pre-approve the Cala Trio nerve stimulator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary.  
 
We looked at the file and Medicare rules. This device is requested for the treatment of tremor, a motor function 
disorder. Based on this information, we decided that Medicare rules for coverage of the Cala Trio nerve 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cala Trio 
nerve stimulator (K1018, K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom shaped protective cover (L5704). 
 
You asked the Plan to pre-approve a custom shaped protective cover. You say that a cover will help prevent 
dust and dirt from getting inside the mechanism of the enrollee's prosthesis. The Plan denied your request. The 
Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a custom shaped protective cover (L5704).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Reader. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
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 Freestyle Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you can keep the wheelchair locked in 
the car and use it in the community. The Plan denied your request. The Plan says that the requested power 
wheelchair is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan has to pay for a short-latency somatosensory evoked potential study (code 95938), 
evoked potentials and reflex testing procedures (coding 95939), electromyography procedures (code 95861) 
and EEG testing (code 95957) provided on September 26, 2022. 
 
You asked the Plan to pay for a short-latency somatosensory evoked potential study (code 95938), evoked 
potentials and reflex testing procedures (coding 95939), electromyography procedures (code 95861) and EEG 
testing (code 95957). You say that the services are medically necessary. The Plan denied your request. The 
Plan says that this expense does not meet this requirement of the members plan and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Plan rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for a short-latency somatosensory 
evoked potential study (code 95938), evoked potentials and reflex testing procedures (coding 95939), 
electromyography procedures (code 95861) and EEG testing (code 95957) provided on September 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Keytruda rendered on June 1, 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 were not medically necessary. 
 
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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found Keytruda in combination with axitinib is 
approved by the Food and Drug Administration (FDA) for first line treatment of advanced renal cell carcinoma 
and treatment is until toxicity or progression. However, there are no recent medical records beyond June 1, 
2022 in the submitted documentation. There is no documentation of recent imaging and assessment of toxicity. 
The records do not support that Keytruda was reasonable and 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 pay for the Keytruda rendered on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments (97810). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  
 Specifically, the acupuncture services in this case were not requested on the basis of a diagnosis for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments 
(97810).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Perforomist. 
 
You asked the Plan to pre-approve Perforomist. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Perforomist.  
 
Benefits for Perforomist 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve F2 and F5 gene analysis. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to 
pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 
20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, 
Leiden variant (81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that SSBCI is medically necessary. The Plan denied your 
request. The Plan says no additional supporting documentation was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. Therefore, we 
decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI).