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

 
We decided that the Plan does not have to pay for procedure code 35631 for date of service October 11, 2022. 
 
You asked the Plan to pay for procedure code 35631. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is missing an anatomical modifier. 
 
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, the CPT Code Manual definition of code 35631 is bypass graft, with other than vein; aortoceliac, 
aortomesenteric, aortorenal. 
 
We find that CPT code 35631 is not supported in the medical record. Specifically, this code was billed without 
an anatomical modifier. The documentation shows that this procedure was bilateral, so this code should have 
modifier 50 appended. The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 35631 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 35631 for date of service October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the enrollee is unable to use crutches or a 
walker. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for this 
product.  
 
   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter (E0118).
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 is a 70-year-old who was admitted to the acute care hospital with septic 
shock, osteomyelitis of left hip, and hypotension requiring antibiotics, fluids, complicated by pressure ulcer, 
respiratory failure and pleural effusion requiring wound care, thoracentesis, and vent support. Trach was placed. Recent notes describe the patient now with stable blood pressure, tolerating weaning on CPAP mode, 
but has significant pleural effusion and mucous plugging requiring thoracentesis, Mucomyst, and 
bronchodilators.  
1. The enrollee appears to be improving with current treatment but is still requiring short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. Completion of 
treatment at the current facility is 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92014) provided on 
November 3, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the service you received was a 
routine eye exam, not a medical exam, and this should be covered in full. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Vision care.  
 
 You have been asked to pay a $20 copayment for the eye exam. This service falls within the Vision care benefit 
category. Specifically, the record shows that you received a medical eye exam, and not a routine exam. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the medical eye exam (92014) provided on November 3, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 10-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
appointments. The Plan denied your request. The Plan says the requested trips exceed your transportation 
benefit. 
 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 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
10-trip limit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ReActiv8 device procedure (64555, 64590, C1767, 
and C1778). 
 
You asked the Plan to pre-approve the ReActiv8 device procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 ReActiv8 device procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation is not evident regarding clear documentation supporting 
that he is not a surgical candidate. Additionally, there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 ReActiv8 device procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the ReActiv8 device procedure (64555, 64590, C1767, and C1778).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home. They 
require IRF services in order to get stronger. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs to check insulin 2 
times daily. The Plan denied your request. The Plan says the enrollee is only on insulin one time per day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy services (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of bioimpedance spectroscopy in patient management. As 
such, bioimpedance spectroscopy is still considered investigational.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy services (93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that this is a medically necessary device. 
The Plan denied your request. The Plan says the criteria for this device are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ventilator. Our reviewer 
says that the requested ventilator is not medically necessary in this case. Our physician reviewer found this enrollee has severe COPD and myasthenia gravis. The enrollee has had a Life2000 device since at least 2018, 
which is used during activity. There is no documentation of chronic carbon dioxide retention with an arterial 
blood gas done while stable. Spirometry has been consistent with severe combined obstructive and restrictive 
lung disease. Clinical notes indicate the myasthenia gravis has been stable. Maximum inspiratory and 
expiratory mouth pressures are normal.   
 
The Life2000 system is not a true ventilator, because it is not capable of providing full ventilatory 
support. There is inadequate evidence of the safety and efficacy of this device in the treatment of COPD or 
restrictive lung disease.  
 
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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Life2000 ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery 
pressure monitor. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this device will be beneficial for 
the enrollee's condition. The Plan denied your request. The Plan says this is not a proven treatment at this time. 
 
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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive, non-implanted continuous glucose 
monitor (CGM) described by code E2103 and supplies. 
 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 criteria for coverage are not met. 
 
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 treat with 
insulin three or more times per day. 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 non-
adjunctive, non-implanted continuous glucose monitor (CGM) described by code E2103 and supplies.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9126 billed for date of service April 1, 
2022, to April 30, 2022. 
 
You asked the Plan to pay for procedure code S9126. You say that you are appealing with proof of medical 
necessity. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9126 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9126 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9126 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9126 billed for date of service April 1, 2022, to April 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara infusions to be provided in the enrollee's home.  
You asked the Plan to pre-approve Stelara infusions in the enrollees home. You say that the enrollee had 
extensive cardiac surgery less than a year ago. You say that the enrollee is still recovering. You say that the 
enrollee has other conditions which make it difficult for them to leave the house. You also say that it is not easy 
for them to go sit in an infusion center for hours at a time. The Plan denied your request. The Plan says the 
documentation does not support that the enrollee is homebound. 
 
The Plan must follow Medicare rules. Medicare rules say that The Plan must follow Medicare rules. The rules 
say that an enrollee must be homebound for infusion services to be covered in your home.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Stelara infusions in the enrollees home have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Stelara infusions to be provided in the enrollee's home.  
 
Benefits for Stelara infusions in the enrollees home may be available under Medicare Part D, and you may 
choose to pay out-of-pocket for an infusion company to administer the drug in your home. 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 urine PCR (polymerase chain reaction) panel provided on 
October 10, 2022, billed with codes 87653, 87641, 87481, 87651, 87798 and 87500. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urine PCR (polymerase chain reaction) panel provided on October 10, 2022, billed with codes 87653, 
87641, 87481, 87651, 87798 and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that the codes are payable. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, 
billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272.