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

 
We decided that the Plan does not have to pre-approve the physician services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the physician services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says there are network providers available. 
 
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 
the physician services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker and seat attachment. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you do not meet the weight requirement for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If an 
E0148 or E0149 walker is provided and if the beneficiary weighs 300 pounds or less, it will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty walker and seat attachment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy-duty walker (E0149) and seat attachment (E0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity prosthesis addition, 
flexion/extension wrist with or without friction (L6621), a microprocessor control feature, addition to upper 
limb prosthetic terminal device (L6882) and an electric hook, switch or myoelectric controlled, adult (L7009). 
 
You asked the Plan to pre-approve prosthetics. You say that the enrollee needs the requested prosthetics for 
quality of life. The Plan denied your request. The Plan says the current prosthesis is less than a year old. 
Medicare does not cover replacement for items under warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
 The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve an upper extremity prosthesis addition, flexion/extension wrist with or without friction (L6621), a 
microprocessor control feature, addition to upper limb prosthetic terminal device (L6882) and an electric hook, 
switch or myoelectric controlled, adult (L7009).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injection. 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diapers (A4520), alcohol wipes (A4245), gloves 
(A4927), Enteral formula (B4152), food thickener (B4100), and Enteral supplies (B9998). 
 
You asked the Plan to pre-approve incontinence supplies and nutritional supplies. You say that the items are 
medically necessary. The Plan denied your request. The Plan says These are not covered items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Medicare does not pay for nutritional supplements. 
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the diapers (A4520), alcohol 
wipes (A4245), gloves (A4927), Enteral formula (B4152), food thickener (B4100), and Enteral supplies 
(B9998).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing for the CALR (calreticulin), JAK2 (Janus kinase 
2), JAK and MPL (MPL proto-oncogene, thrombopoietin receptor) genes (81219, 81279, 81270 and 81339). 
 
You asked the Plan to pre-approve testing for the CALR, JAK, JAK2 and MPL genes. You say that this testing 
is medically necessary. The Plan denied your request. The Plan says this testing is not medically necessary, as 
the records do not show that the enrollee has had sequential testing performed starting with the BCR-ABL 
testing. 
 
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 testing for the CALR, JAK, JAK2 and 
MPL genes. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not show that the enrollee has had 
sequential testing performed starting with the BCR-ABL testing. The review has determined that the 
items/services at issue in this case are 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 testing for the CALR, JAK, JAK2 and MPL genes have not been met. 
Therefore, we decided that the Plan does not have to pre-approve testing for the CALR (calreticulin), JAK2 
(Janus kinase 2), JAK and MPL (MPL proto-oncogene, thrombopoietin receptor) genes (81219, 81279, 81270 
and 81339).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. You asked the Plan to pre-approve SNF care. You say that you need SNF care as you live alone and do not 
have the strength in your hands to care for yourself. The Plan denied your request. The Plan says you do not 
meet the requirements for a SNF admission. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were not hospitalized and are functioning at a home care level. You do not 
require daily skilled nursing or daily skilled therapy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the enrollee clearly exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the request 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. 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 Plan. Given there are offered alternatives, LTACH is 
not 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the criteria for coverage of Injectafer have not been met. Our physician reviewer found that the Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. In this case, the enrollee has not tried 
and failed both of the required drugs. There is no documentation provided indicating that the Plan's required 
drugs would likely be less effective or likely have adverse effects 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of lymphedema extending onto the chest, trunk, or abdomen 
beyond the limits of a standard compression sleeve. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has lymphedema of the legs and possibly involving the abdomen. That said, it is not 
clear the requested device has evidence for abdominal edema. Although it states that prior pumps have failed, 
there are no measurements before and after. Overall, given the unclear efficacy of the trunk element of the 
pump, it is not clear that the requested device is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service June 29, 2023. 
 
You asked the Plan to pay for the billed service. You say that the records support medical necessity. The Plan 
denied your request. The Plan says the claim was submitted with an incorrect type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. We find that the claim at issue did not include a type of bill code suitable 
for payment. Based on this information, we decided that Medicare rules for coverage of the billed service have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health care billed for date 
of service June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 3, 2023, billed with 
evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 We asked our physician 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation from this date 
describes the enrollee as having presented 2 days prior with small bowel obstruction, treated with medical 
treatment, no surgery, and plans for hernia reduction were being made. The enrollee was reported as stable 
medically with nontender abdomen. The documentation did not support a high level of medical decision 
making, nor did it provide evidence of the encounter from this date lasting 50+ minutes as required for the 
code, 99233.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 3, 2023, billed with evaluation and 
management (EM) code 99233.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF 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 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary 
because there is little evidence in the medical literature to suggest that this is an appropriate procedure for the 
member's back pain. It is not an accepted standard of medical practice for the diagnosis of back pain. It is 
considered experimental and 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device provided on April 7, 2023. 
 
You asked the Plan to pay for the billed service. You say that the services should be reimbursed. The Plan 
denied your request. The Plan says durable medical equipment must be provided through a Medicare certified 
provider. 
 
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. 
 
We looked at the file and the rules. A 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 the 
oral device provided on April 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96375, 96413, J2930, Q5104) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 codes 96375, 96413, J2930, and Q5104, are not supported in the medical record. 
Specifically, the records provided do not indicate the date of service. Without the date of service on the records, 
the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(96375, 96413, J2930, Q5104) provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid-19 testing code K1034 billed for date of service 
July 12, 2023.  
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the test is not 
covered. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. Coverage for 
OTC Covid-19 testing ended on May 11, 2023. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Covid-19 
testing code K1034 billed for date of service July 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73562-LT, 73630-RT, 73610-RT, and 76882-LT billed 
for date of service June 26, 2023. 
 
You asked the Plan to pay for codes 73562-LT, 73630-RT, 73610-RT, and 76882-LT. You say that these are 
payable codes. The Plan denied your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning that they are STV-packaged services.  These disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 73562-LT, 73630-RT, 73610-RT, and 76882-LT have not been met. Therefore, we decided 
that the Plan does not have to pay for codes 73562-LT, 73630-RT, 73610-RT, and 76882-LT billed for date of 
service June 26, 2023.