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

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve wig. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not covered by Medicare. 
 
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 pre-approve a wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that you would like reconsideration because the stair 
lift is necessary for you to get into your home after you are discharged from skilled nursing.  The Plan denied 
your request. The Plan says the requested stair lift is not covered because it is considered a convenience item 
and not primarily medical in nature.  
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myopro. 
 
You asked the Plan to pre-approve Myopro. 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. 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 Myopro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a cervicothoracic spinal fusion in 2022 complicated by a bilateral C8 palsy 
(right worse than left). The enrollee has had occupational therapy with only mild improvement. The MyoPro 
Orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, 
in improving health outcomes. The MyoPro is not the standard of care for this enrollee's cervical nerve condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee. 
There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 
Therefore, the enrollee does 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 Myopro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myopro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 99153 billed for date of service December 
30, 2022. 
 
You asked the Plan to pay for procedure code(s) 99153. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components are payable when the enrollee is not a patient of any hospital, and the service is received 
in a setting that is not part of a hospital. 
 
The Plan has not submitted evidence that indicates this service was provided to the enrollee while an inpatient 
or outpatient in any hospital. In this case, CPT code 99153 does not need to be billed with a modifier to 
indicate the professional component only. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99153 have been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 99153 billed for date of service December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 20, 2023. 
 
You asked the Plan to pay for the medical services. You say that no referral is required for these services. The 
Plan denied your request. The Plan says you billed these services with an invalid pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of M54.2 and M50.222. Code M50.222 is an Excludes1 code 
under code M54.2, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee arthroscopy provided on January 30, 2023. 
 
You asked the Plan to pay for a knee arthroscopy. You say that this procedure was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained for this surgery. 
 
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 pay for a knee arthroscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided diagnostic imaging studies demonstrated a not insignificant overall arthritic 
process of the left knee. Recent, reasonable, and comprehensive less invasive treatments have not been clearly 
denoted to have been tried and failed. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. 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 a knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for a knee arthroscopy provided on January 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a SPRINT peripheral nerve stimulator. You say that the enrollee is in pain 
and needs this procedure. The Plan denied your request. The Plan says medical studies have not proven this 
item is helpful for the treatment of the enrollee's health problem. 
 
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 SPRINT peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence that a SPRINT peripheral nerve 
stimulator would be effective, safe, and cost-effective in the enrollee's profile, and is thus not medically 
reasonable. 
 
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 SPRINT peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator 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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has severe COPD with a recent hospitalization for an exacerbation. Arterial blood gas (ABG) was 
consistent with acute on chronic hypercarbic respiratory failure. The enrollee improved with BiPAP 
therapy. The enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) during 
sleep as an outpatient. This treatment has not been tried and shown to fail as an outpatient. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. Alarms and battery backup are 
not medically necessary for 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285, 83880, 82977, 80053) 
provided on August 1, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the provider is not enrolled in Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room services (99285, 
83880, 82977, 80053) provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 16, 2023.  
 
You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that the test provides 
valuable information that assists in determining the appropriate medication at the appropriate dosage. The Plan 
denied your request. The Plan says ordering a multi-class panel of definitive urine drug tests that are not used 
in clinical management, exceeds the needs of the enrollee. 
 The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter 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 pay for definitive UDT for 22 or more drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that there was no 
indication for definitive testing in this case. There is no history of drug abuse, diversion or inconsistent results. 
The testing was not medically reasonable and 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 definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on January 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9595 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code A9595. You say that you have billed the item or service at issue 
correctly. The Plan denied your request. The Plan says the billed code is a statutory exclusion. 
 
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 A9595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A9595 is a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of procedure code A9595 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A9595 billed for date of service November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on March 17, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you have supplied medical records to show 
the medical necessity of these supplies. The Plan denied your request. The Plan says you billed this claim with 
an invalid pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of E11.65 and E13.403. Code E13.403 is an Excludes1 code 
under code E11.65, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for diabetic supplies provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87636 billed for date of service December 26, 2022. 
 
You asked the Plan to pay for code 87636. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 87636 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 87636 billed for date of service 
December 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry with electrocardiographic 
recording. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary as the records do not show that you have been considered for or had unsuccessful 
traditional monitoring, such as a Holter monitor. 
 
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 external mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
supportive evidence that the ordering practitioner documented any standard, non-mobile cardiac outpatient 
telemetry ambulatory echocardiogram monitoring. There is insufficient documentation to support the medical 
necessity for a mobile cardiac outpatient telemetry monitor in your 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 external mobile cardiovascular telemetry with electrocardiographic recording 
have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile 
cardiovascular telemetry with electrocardiographic recording (93228).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary to help the enrollee 
become self-sufficient and go home. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for admission to an IRF.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4216, A4221, A4222) provided on 
January 27, 2023 to February 1, 2023. 
 
You asked the Plan to pay for the infusion supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery which supports the supplies provided in this case. No 
itemized delivery documentation was provided. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
infusion supplies (A4216, A4221, A4222) provided on January 27, 2023 to February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on January 
28, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. 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 molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. Once this is 
complete, the test is assigned a reimbursement rate and unique test identifier. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on January 28, 
2023.