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

 
We decided that the Plan does not have to pre-approve the high compression bandage (CPT code A6452). 
 
You asked the Plan to pre-approve the bandage. You say that the bandage is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 bandage. Our physician reviewer found the record indicates that you have chronic venous insufficiency without any open wound.   The requested 
service is excluded by rule for your clinical condition. The elements of the coverage criteria are not satisfied. 
The requested service is not recommended. 
 
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 bandage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the high compression bandage (CPT code A6452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stab phlebectomy of varicose veins, 1 extremity; 10-
20 stab incisions (CPT code 37765) and enndovenous ablation therapy of incompetent vein, extremity, 
inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated (36475). 
 
You asked the Plan to pre-approve the services. You say that the pain and swelling does significantly affect the 
enrollee's daily activities. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 services. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. The documentation does not support the enrollee is having significant symptoms. It is 
documented that the enrollee describes their symptoms as 1 out of 10 in severity. It is noted that the stockings 
help the enrollee. Therefore, the documentation does not support coverage of vein treatments. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (CPT code 
37765) and enndovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 
and monitoring, percutaneous, radiofrequency; first vein treated (36475).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PVA procedure (CPT code(s): 22513 and 22515). 
 
You asked the Plan to pre-approve the surgical services. You say that the surgical services are necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 surgical services. Our physician 
reviewer found the medical records do not show that the fracture is less than 6-12 weeks old on imaging 
studies. 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 surgical services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a PVA procedure (CPT code(s): 22513 and 22515).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553) 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you need to check your blood sugar 
daily. Your tips of your fingers are painful because you have been doing this since 2007. You need this sensor 
approved to have a good quality of life. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for the requested service. 
 
 
 
 
 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 the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable bed (E1399) purchased April 2, 2022. 
 
You asked the Plan to pay for the adjustable bed. You say that please reconsider and process this claim to be 
paid for reimbursement due to medical necessity per your doctor's orders. The Plan denied your request. The 
Plan says a copy of the primary Explanation of Benefits has not been received. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the records show that the 
enrollee has Primary coverage through spouses Plan. As the secondary insurer, the Plan cannot be held 
responsible for the adjustable bed until the primary insurer has denied the claim for these services. Review of 
the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The 
rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the adjustable bed (E1399) purchased April 2, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Medicare guidance says a subcutaneous injection (a shot under the 
skin) that can be self-administered is covered by the pharmacy (drug) benefit. 
 
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 injection.   
Benefits for the medication 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 pay for the xT Heme genomic panel provided on May 8, 2022, billed 
with code 81455. 
 
You asked the Plan to pay for the genomic panel as billed. You say that this is medically necessary testing 
which should be reimbursed. The Plan denied your request. The Plan says all lab tests must report the date of 
service as the date the sample was taken. Since this was not done on this claim, it cannot be paid. 
 
Please note: The Plans denial rationale was disregarded as it has not been interpreted correctly. We made our 
decision based on the rules cited below. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 
81450 may be covered by Medicare.  
 
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for the xT Heme genomic panel provided on May 8, 2022, billed with code 81455.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nutritional services (CPT code(s): B4185, B4193, 
B4197, B4189). 
 
You asked the Plan to pre-approve the nutritional services. You say that the services are necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
they do not have an underlying intestinal or exocrine gland disorder that reduces the enrollee's ability to absorb 
nutrients. 
 
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 nutritional services. Our physician 
reviewer found the review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 nutritional services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the nutritional services (CPT code(s): B4185, B4193, B4197, B4189).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current acute care setting. The 
LTACH does not offer any services that are not currently available to the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) 
system (K0554). 
 
You asked the Plan to pre-approve a CGM system. You say that the CGM is medically necessary. 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 CGM 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) system (K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81455) provided April 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the correct date of service is the date the specimen was collected. 
 
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 looked at the file and Medicare rules. The documentation does not support the billed date of service.  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 (81455) provided April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot insert (CPT code L3000). 
 
You asked the Plan to pre-approve the foot insert. You say that you suffer from back pain and the pain and 
mobility gets worse each day. The Plan denied your request. The Plan says your request is not a covered benefit 
because your records show you do not have this shoe insert as part of a brace, nor is it medically necessary for 
the proper function of a brace. The Plan states your records do not say you have diabetes and thus, this insert 
are not for the prevention of diabetic foot wounds. The Plan states you do not have amputation of any part of 
your feet. 
 
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 foot insert (CPT code L3000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BRCA1, BRCA2 gene analysis; full sequence analysis 
and full duplication/deletion analysis (81162). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee should have this test completed as 
she has an elevated lifetime breast cancer risk secondary to personal and family history. The requested testing 
is medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say genetic testing for a known mutation in a family is a 
covered service for individuals with signs and/or symptoms of cancer.  
 
We looked at the file and Medicare rules. The records show that you do not have signs or symptoms of cancer. 
Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a BRCA1, BRCA2 gene analysis; full 
sequence analysis and full duplication/deletion analysis (81162).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62323). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the injection is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injection is covered when the first injection 
directly and significantly provided improvement of the condition being treated may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using the same scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that the injection is not medically necessary. Our physician reviewer found there is no 
documentation that the enrollee had a prolonged treatment trial of non-steroidal anti-inflammatory agents. 
There was no documentation to support that the pain is intractable and affecting activities of daily living. The 
enrollee had a prior epidural steroid injection that resulted in more than 50% pain relief, but the date of that 
injection is unknown. 
 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for superficial radiation therapy 
(CPT code G6001 X 25). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence to show that this 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found certainly using ultrasound on a daily basis is not unreasonable, but to bill for daily simple 
simulations (also requested in this case) and/or IGRT for a technology for which need has not been established 
by published data or supported by consensus guidelines. Billing for daily simulations or image-guided radiation 
therapy (IGRT) 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guidance for superficial radiation therapy (CPT code G6001 X 25).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Forteo is required before alternatives can be considered. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug, 
or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cranial prosthesis provided February 28, 2022. 
 
You asked the Plan to pay for the cranial prosthesis. You say that you were told by a Plan representative that 
you would have to get a statement from your doctor verifying that your request for your cranial prosthesis was 
not for cosmetic reasons. The Plan denied your request. The Plan says this item is not covered. 
 
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 not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the cranial prosthesis 
provided February 28, 2022.