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

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that this device is widely 
prescribed at some of the most esteemed institutions. You also say that the device has been embraced by 
clinicians nation-wide and recommended in the American Heart Association guidelines for stroke rehabilitation 
as the only available treatment for individuals with moderate to severe upper limb paresis. The Plan denied 
your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro Motion G Orthotic device. 
Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. Our reviewer found 
that the MyoPro is not in widespread use based on scientific evidence. 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. Our physician reviewer also found that 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 Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens enhancement (V2784), provided on December 22, 
2021. 
 
You asked the Plan to pay for the lens enhancement (V2784), provided on December 22, 2021.. You say that 
item should be covered. The Plan denied your request. The Plan says this is not a covered item. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan states that lens enhancements are not covered through the allowance but may be purchased 
by the member at an additional cost. 
 
We looked at the file and the Plan's rules. Lens enhancements are not covered through the allowance but may 
be purchased by the member at an additional cost. Based on this information, we decided that the Plan's rules 
for coverage of the lens enhancement (V2784), provided on December 22, 2021 have not been met. Therefore, 
we decided that the Plan does not have to pay for the lens enhancement (V2784), provided on December 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urine PCR panel testing (CPT code(s): 87511, 87640, 
87798) provided on June 14, 2021. 
 
You asked the Plan to pre-approve the urine PCR panel testing. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the standard of care for the evaluation of urinary 
incontinence is urinalysis with urine culture and sensitivity. The Plan states the PCR testing is considered 
unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the urine PCR panel testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review has determined that the medical records provided did not meet 
the requirements listed in the NCD 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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve urine PCR panel testing (CPT code(s): 87511, 87640, 87798) provided on 
June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME purchased and rented on August 3, 2021, through 
September 9, 2021, from non-Medicare certified providers.  
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. 
The Plan denied your request. The Plan says the services were obtained from providers who were not under 
contract with the health plan and are not certified for Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that you 
purchased and rented these DME items from non-Medicare certified providers. Therefore, we decided that the 
Plan does not have to pay for the DME purchased and rented on August 3, 2021, through September 9, 2021, 
from non-Medicare certified providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear enhancements provided on February 7, 2022. 
 You asked the Plan to pay for the eyewear enhancements. You say that the items should be covered. The Plan 
denied your request. The Plan says vision enhancements are not covered under the Plan's allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan states that enhancements are not covered through the allowance but may be purchased by 
the member at an additional cost. 
 
We looked at the file and the Plan's rules. enhancements are not covered through the vision allowance but may 
be purchased by the member at an additional cost. Based on this information, we decided that the Plan's rules 
for coverage of the eyewear enhancements have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyewear enhancements provided on February 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit to be dispensed by a specialty pharmacy. 
 
You asked the Plan to pre-approve Procrit. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is 
covered by Medicare Part D when a pharmacy dispenses the drug. The Plan also says that they have approved 
authorization for this drug through the enrollee's Medicare Part D prescription drug benefits, so this denial only 
pertains to Medicare Part B prescription drug benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Procrit to be dispensed by a specialty pharmacy.  
 
Benefits for Procrit 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 GeneSight testing provided on November 11, 2021. You asked the Plan to pay for the testing services. You say that the test informs clinicians about which 
medications may require dose adjustments. The Plan denied your request. The Plan says the test has not been 
shown to be useful. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There are insufficient data to support coverage for any combinatorial 
test. Based on this information, we decided that Medicare rules for coverage of the testing services have not 
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on 
November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve an addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable. You say that the denial is erroneous, and you are requesting reconsideration. The Plan denied your 
request. The Plan says the knee unit already comes with a knee flexion as a part of the knee adjustability. 
 
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 been approved for all prosthetics requested except the additional, endoskeletal, 
knee-shin system, stance flexion feature. The Plan says that Medicare does not cover this request for any reason 
because the knee unit approved already comes with a knee flexion as a part of the knee adjustability. Therefore, 
we decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on November 10, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that as a general rule, the date 
of service for a clinical laboratory test or the technical component of physician pathology service must be the 
date the specimen was collected. The provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the submitted records are 
limited and partially illegible. The records also indicate that the specimen was collected on October 19, 2021, 
rather than the billed date of service. Based on this information, we decided that Medicare rules for coverage of 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services (81479) provided on November 10, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee requires skilled 
nursing services per clinical documentation as enrollee has been having frequent hypoglycemic episodes and 
requires monitoring of volume status. Per evaluating therapies, the enrollee has new mobility and activities of 
daily living impairments and requires skilled therapy services. From a practical standpoint, documentation 
provides evidence that the enrollee requires daily skilled nursing and therapy services on an inpatient basis in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve injection. You say that you need the injection because you had it before, and 
it works with reducing your pain. You also say that you have pain getting up and down the stairs and moving 
around. The Plan denied your request. The Plan says the provided documentation does not indicate that you 
have had more than 50% pain relief after the previous injection. The Plan also says that the requested service is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested sacroiliac (SI) joint injection is supported if at least three tests are positive, 
Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. In this case, the records do not 
show three or more positive test results. Therefore, the reviewer found that the requested sacroiliac joint 
injection is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve sacroiliac joint injection (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
imaging (D0210) provided by an out-of-network provider December 21, 2020. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral imaging. You say that you were 
told that this dentist was in-network. The Plan denied your request. The Plan says the rendering dentist is out-
of-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and intraoral imaging when the services are provided by an in-network provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and intraoral imaging have not been met.  Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and 
intraoral imaging (D0210) provided by an out-of-network provider on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palatopharyngoplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the medical literature, this procedure is one that exceeds medical needs. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has mild to moderate obstructive sleep apnea and has been 
recommended for a continuous positive airway pressure (CPAP) trial. The record provided indicates that the 
enrollee is nasal reconstructive surgery for nasal obstruction and wishes to avoid CPAP. The requested service 
exceeds the enrollee's requirements for care at this time. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve palatopharyngoplasty for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen 
(74170) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an abdominal CT scan. You say that the service at issue is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
services have not been met. 
 
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 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 
a computed tomography (CT) scan of the abdomen (74170) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on September 29, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says the POS code reported is not correct. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Specifically, this claim was billed with the office POS code. 
The records indicate that this sample was taken in an outpatient hospital facility setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing provided on September 29, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-
articular injection (J7321). 
 
You asked the Plan to pre-approve Hyaluronan or derivative injection. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says that a repeat series of injections cannot 
be performed because 6 months have not passed since the last injection series. 
 
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. In this case, we requested additional information to verify the Plans denial. 
Specifically, there were medical records included that indicated that the last injection series was in 2019. The 
enrollee confirms in the record that an injection has not been received since. We requested clarification from 
the Plan regarding the reasons for their denial. A response to our request for information was not returned. 
Therefore, we decided that the Plan has to pre-approve Hyaluronan or derivative, hyalgan, supartz or visco-3, 
for intra-articular injection (J7321).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric visit (99214) billed for date of service July 27, 
2021. 
 
You asked the Plan to pay for a psychiatric visit. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
available medical records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99214 for date of service July 27, 2021, is not supported in the medical record. 
Specifically, the only medical records provided were for another date of service (July 21, 2021). Based on this 
information, we decided that Medicare rules for coverage of a psychiatric visit have not been met. Therefore, 
we decided that the Plan does not have to pay for a psychiatric visit (99214) billed for date of service July 27, 
2021.