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

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (CPT code E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the oxygen equipment being 
provided by the Health Plan is too heavy for you to carry. The Plan denied your request. The Plan says they do 
not cover duplicate or redundant durable medical equipment such as oxygen device when the second item 
performs the same function as the one currently provided to you. There is no medical documentation to support 
your need for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The file shows that you have the oxygen device. the oxygen device serves the same 
purpose as [Shorter description of the portable oxygen concentrator. Therefore, we decided that the Plan does 
not have to pre-approve the portable oxygen concentrator (CPT code E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity assist device (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity assist device. You say that this device is 
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 pre-approve the powered upper extremity assist 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis 
will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long 
term use. 
 
 
 
 
 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 powered upper extremity assist device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered upper extremity assist device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (spinal cord stimulator trial) for cervical spine. 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural 
(spinal cord stimulator trial) for cervical spine. The Plan denied your request. The Plan says based on Medicare 
guidelines, the percutaneous implantation of neurostimulator electrode array, epidural (spinal cord stimulator 
trial) for your cervical spine that you and/or your provider is/are requesting does not meet the requirements for 
approval. 
 
The Plan follows Medicare rules. 
 
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 percutaneous implantation of 
neurostimulator electrode array, epidural (spinal cord stimulator trial) for cervical spine. Our reviewer says that 
percutaneous implantation of neurostimulator electrode array, epidural (spinal cord stimulator trial) for cervical 
spine is not medically necessary. Our physician reviewer found the enrollee does not have an evidence-based 
indication for a spinal cord stimulation trial.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural (spinal 
cord stimulator trial) for cervical spine have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous implantation of neurostimulator electrode array, epidural (spinal cord stimulator 
trial) for cervical spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
November 1, 2021, through November 30, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed. The Plan 
denied your request. The Plan says payment cannot be made for these services as billed. 
 
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 skilled nursing facility (SNF) care 
provided from November 1, 2021, through November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom orthopedic shoes and inserts. 
 
You asked the Plan to pre-approve the custom orthopedic shoes and inserts. You say that you need a brace that 
is more substantial to hold your bones in place in your foot. You state when you walk your bones rub together, 
and it is very painful. You state you cannot walk normal to begin with and the brace you have is tight, it is 
difficult to get on. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   Records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve the custom orthopedic shoes and inserts.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70450 and 70481 billed for date of service 
March 17, 2022. 
 
You asked the Plan to pay for procedure codes 70450 and 70481. You say that the enrollee had multiple exams 
on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
the payment for 70496, and the payment for code 70481 is bundled into payment for code 70450. 
 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, and code 70481 is a column II code to column I code 70450. 
These claim lines have not been billed with an appropriate modifier to bypass the edit. Based on the claims 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 70450 and 70481 billed for date of service March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the shoe inserts. 
 
You asked the Plan to pre-approve the shoe inserts. You say that you need the insert to help the pain in your 
foot. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pre-approve the shoe inserts.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of soft tissue localization device (10035) 
provided on February 14, 2022. 
 
You asked the Plan to pay for the placement of soft tissue localization device (10035). You say that the 
attached reports support the level of service, and the claim should be reconsidered for processing. The Plan 
denied your request. The Plan says CPT code 10035 is included in CPT code 19083 and 19084. 
 
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 10035 is a column II code to column I code 19083 and 19084; 
however, 10035 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the placement of soft tissue localization device (10035). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the procedure report describes placement of localization device and left breast biopsy and 
axillary. No additional localization device placement was documented. Therefore, modifier -59 cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the placement of soft tissue localization device (10035) have not been met. 
Therefore, we decided that the Plan does not have to pay for the placement of soft tissue localization device 
(10035) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on March 17, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was initiated 
by the laboratory and not by the member's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The genetic testing in this case was not ordered by the enrollee's 
treating physician. 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 cardiovascular genetic testing provided on 
March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Supartz (J7321). 
 
You asked the Plan to pre-approve Supartz. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested drug have 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 Supartz. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that, based 
on the medical records provided and the Medicare-approved drug compendia, there is no documentation that 
the Supartz at issue in this case meets Medicare criteria for medically reasonable and necessary. Provided 
records do not document the enrollee's response to the most recent physical therapy referral. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Supartz (J7321).
Appeal type: Practitioner Services
Decision: Favorable

 ` 
We decided that the Plan has to pre-approve continued chiropractic treatment. 
 
You asked the Plan to pre-approve this service. You say that continued chiropractic care is medically 
necessary. The Plan denied your request. The Plan says that you have reached the maximum therapeutic 
benefit. Your continuous care and lack of clinical improvement indicates your care is supportive and is 
therefore, maintenance care, not covered by the Plan. 
 
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 when there is an expectation of improvement in 
function.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that 
continued chiropractic treatment is medically necessary. Our physician reviewer found that your listed 
diagnoses are segmental and somatic dysfunction of the lumbar region, segmental and somatic dysfunction of 
the cervical region, lumbago with sciatica of the left side, and radiculopathy, of the cervicothoracic region. The 
available clinical documentation in the case file does not support the plan's denial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve continued chiropractic treatment.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital clinic visit (G0463) and x-ray of abdomen 
(74019) provided on April 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital clinic visit and x-ray. The Plan denied your request. The Plan says 
the services were provided out-of-network and 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 the hospital clinic visit (G0463) and x-ray of 
abdomen (74019) provided on April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that the enrollee qualifies for maintenance care. The Plan 
denied your request. The Plan says over the previous 30 visits the deficits remain unchanged, and the therapy 
appears repetitive. The Plan also says the therapy with seated and supine exercises should be able to be safely 
performed through a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent slow deterioration of the enrollee's 
condition. Our physician reviewer found the patient has had prior extensive therapy and the documentation 
does not reveal that the patient requires the unique skills of a professional therapist to safely and effectively 
provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 20 physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 10, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on May 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says the criteria has not been met for additional physical 
therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee is able to ambulate without assistive device. 
She can work on her endurance to increase walking tolerance independently. She does not require ongoing 
formal PT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy sessions provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on December 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an outpatient clinic visit provided on December 
21, 2021, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal trainer. 
 
You asked the Plan to pre-approve a personal trainer. You say that  The Plan denied your request. The Plan 
says services with a personal trainer are not covered by Medicare or under this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover fitness benefits.  
 
The services at issue in this appeal are fitness benefits. Therefore, we decided that the Plan does not have to 
pre-approve a personal trainer.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neuropsychological testing evaluation services 
(96130). 
 
You asked the Plan to pre-approve the neuropsychological testing. You say that you are requesting approval of 
the authorization based on the enrollee's medical records. The Plan denied your request. The Plan says the 
records do not support that this service is medically reasonable or 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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on review of the records provided, the enrollee was not found to be 
depressed based on his PHQ 9. The enrollee was ordered neurocognitive testing based on his diagnosis of mild 
cognitive impairment, so stated although there is no documentation presented as to the severity of his cognitive 
status based on exam. Based on review the records provided utilizing LCD L35101 and the information 
provided this enrollee does not meet the criteria for psychological testing and could be evaluated on an 
outpatient basis with the physician. 
 
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 neuropsychological testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the neuropsychological testing evaluation services (96130).