Persius/hicric huggingface dataset:
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 you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
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 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found you have severe chronic obstructive pulmonary disease (COPD). You had a recent 
hospitalization for an exacerbation. There is no documentation of chronic carbon dioxide (CO2) retention on an 
arterial blood gases done as an outpatient while stable. Bi-level positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) has not been tried. The documentation shows that you were intolerant of a ventilator with AVAPS in the hospital. Medicare does not cover a home ventilator when used as 
BiPAP. Therefore, you do not meet criteria for the requested device. 
 
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: Favorable

 
We decided that the Plan has to pre-approve an electronic bone growth stimulator, (E0747x2). 
 
You asked the Plan to pre-approve an electronic bone growth stimulator. You say that the device is medically 
necessary. The Plan denied your request. The Plan says that the stimulator is not medically necessary per 
Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 electronic bone growth stimulator. 
Our reviewer says that the service is medically necessary. Our physician reviewer found the consecutive exams 
demonstrate that he went from full weight-bearing to ambulating in a wheelchair. The CT scan from 5/2/22 
stated hardware appears in place. However, bony ankylosis/bony fusion across the first and second 
tarsometatarsal joints is not definitively seen, no acute fracture is evident. The peer-reviewed literature stated, 
there is increasing evidence for its use in the foot and ankle for treatment of non-unions and as an adjunctive 
device in arthrodesis, particularly in high-risk populations. With a noted history of current every day smoker 
of 1 pack per day, he is at increased risk for failed fusion. 
 
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 electronic bone growth stimulator have been met. Therefore, we decided that 
the Plan has to pre-approve an electronic bone growth stimulator, (E0747x2).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on February 17, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that these services were medically necessary and 
reasonable. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M for CxBladder is a noncovered 
service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the requested CxBladder 
testing (0012M) is not a Medicare-covered service. Therefore, we decided that the Plan does not have to pay 
for CxBladder testing (0012M) provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient hospital admission from 
September 1, 2022, forward. 
 
You asked the Plan to pre-approve a continued inpatient hospital admission. You say that the enrollee is 
awaiting inpatient psychiatric placement. The Plan denied your request. The Plan says care does not meet 
Medicare guidelines for continued inpatient care as the enrollee is medically stable and definitive care should 
be provided in the appropriate setting. 
 
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 continued inpatient hospital 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation shows that as of September 1, 
2022, care could have been provided in alternate setting. The enrollee appears clinically stable and is currently 
receiving only oral medications. Exam was unremarkable except for psychiatric issues. Cardiac monitor 
revealed normal sinus rhythm no ectopy. Vital signs are stable. Care did not meet Medicare guidelines for 
continued inpatient care as the enrollee was medically stable and definitive care could be provided in the appropriate setting. The review has determined that the items/services at issue in this case were 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 a continued inpatient hospital admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued inpatient hospital admission from September 1, 
2022, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 22, 
2022. 
 You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not 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.  
 
In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76705 
billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (80061) provided on August 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 82465 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (80061) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document that the 
enrollee has a musculoskeletal condition or the presence of a cast or brace that prevents 90 degree flexion in the 
knee. There is no significant edema of the lower extremities that require an elevating leg rest. The records do 
not fully support that the enrollee is high risk for skin breakdown with documented 4-/5 to 4/5 bilateral upper 
extremity strength. There is no reported history of pressure ulcer(s) or skin flap surgery. Records do not 
document the enrollee has increased lower extremity muscle tone or spasticity. The records do not support that 
the Group 3 PWC with multiple power options is reasonable or 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 pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips as your health is in jeopardy. The Plan denied your request. The Plan says additional trips 
would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
forty-seven (47) one-way transportation trips out of the allowed forty-eight (48) one-way trips approved. Once 
48 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve twenty (20) additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services (0013M) provided on 
March 3, 2022. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this testing is statutorily 
non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for Current 
Procedural Terminology (CPT) codes 0012M and 0013M for CxBladder. Based on this information, we 
decided that Medicare rules for coverage of the CxBladder genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the CxBladder genetic testing services (0013M) 
provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for eyeglasses provided on May 20, 2022. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says that no 
receipt was sent for reimbursement. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that a receipt was submitted to the Plan for 
reimbursement. Therefore, we decided that the Plan has to reimburse you for eyeglasses provided on  
May 20, 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: 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 the requested device. You say that there are programs where you will not 
have to use your fingers to check your sugar. The Plan denied your request. The Plan says you do not meet the 
criteria. 
 
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 does not indicate that you use insulin with at least 
three daily injections, 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 the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries; complete bilateral 
study (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that your doctor requested 
this procedure to assist with a diagnosis of possible carotid artery blockage, due to constant pain in neck area of 
artery. The Plan denied your request. The Plan says services requested do not meet medical necessity. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while you do have cardiovascular risk factors, no symptom or finding 
is documented that would necessitate obtaining a carotid duplex. While you might be a reasonable candidate 
for screening, this is not a covered service. Review of the medical record suggests that the order for the duplex 
was at your request who was concerned as your brother had a recent MI. Again, while screening might be 
reasonable in this case, the determination regarding coverage cannot be overturned on the basis of medical 
necessity.   
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries; complete bilateral study 
(93880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services and an office visit (80305, 99214) 
provided on March 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services and an office visit. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 laboratory services and an office visit (80305, 
99214) provided on March 26, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered 
medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 
complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for gangrene and an above the knee amputation. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 31, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are 
available 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 31, 2022 by an out-of-
network (OON) provider.
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 please review attached supportive 
clinical for LTACH admission. This is the safest discharge plan, allowing the highest potential for the 
enrollee's recovery preventing further deterioration and the best use of medical management. The Plan denied 
your request. The Plan says the request for LTACH admission does not meet criteria and is not medically 
necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where there are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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.