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

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) assessment using 
the ImpediMed L-Dex testing device (93702). 
 
You asked the Plan to pre-approve a BIS assessment using the ImpediMed L-Dex testing device. You say that 
based on the evidence provided and what you believe to be proven medical necessity, you would like this 
procedure to be authorized for the enrollee. The Plan denied your request. The Plan says the requested service 
is not considered medically reasonable and necessary in this case. 
 
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 BIS assessment using the ImpediMed 
L-Dex testing device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a 
history of breast cancer and underwent mastectomy with sentinel node biopsy.  The record indicates that the 
enrollee does not have edema.  Our reviewer found that the safety and efficacy of the requested service to be 
used in the enrollee's clinical condition has not been established. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician 
reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service is not 
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 a BIS assessment using the ImpediMed L-Dex testing device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) 
assessment using the ImpediMed L-Dex testing device (93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care with a tertiary level Urogynecologist. 
 
You asked the Plan to pre-approve care with a tertiary level Urogynecologist. You say that the requested 
tertiary level of care is medically necessary.  The Plan denied your request. The Plan says the requested tertiary 
level of care is not medically necessary.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 care with a tertiary level 
Urogynecologist. Our reviewer says that the requested tertiary level of care is not medically necessary.  Our 
physician reviewer found the plan's denial is medically justified on the basis that it is offering adequate care to 
meet the enrollee's medical needs through referral to a non-tertiary care urologist. There is nothing unique 
about the enrollee's condition that that would make it medically necessary for her to see the requested tertiary 
level urogynecologist. The plan has shown that they have in-network providers who meet the Standards of Care 
required for treatment of the enrollee's condition.  Transcutaneous tibial nerve stimulation (TTNS) and trial of 
Trimethoprim is not considered tertiary level medical 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 care with a tertiary level Urogynecologist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve care with a tertiary level Urogynecologist.
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 enrollee is non-ambulatory and 
cannot use a cane or walker for mobility. He cannot functionally propel a manual wheelchair due to upper 
extremity weakness. He requires a power wheelchair for mobility and accomplishing his daily activities; 
however, there is inadequate clinical documentation regarding why he requires power tilt and recline and 
cannot perform pressure relief. He has no history of skin breakdown. There is also no significant lower 
extremity edema or spasticity that would require power elevating leg rests. There is insufficient information in 
the power mobility evaluation indicating what his level of function is with regards to transfers and why a power 
seat elevator is required. Therefore, the group 3 power wheelchair with power tilt and recline, power seat 
elevator, and power elevating leg rests 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 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Marriage and Family Therapist (LMFT) from January 5, 2023, to January 12, 2023. 
 
You asked the Plan to pay for the LMFT services. You say that this provider treats you for extreme anxiety and 
depression, so these services should be covered. The Plan denied your request. The Plan says services from a 
LMFT are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
In this instance, you saw a provider who is a LMFT.  This is not a valid provider type for Medicare, so these 
services cannot be paid, regardless of appropriateness. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services you received from a Licensed Marriage and Family Therapist (LMFT) from 
January 5, 2023, to January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for dates of service November 
19, 2022, to November 24, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that you believe these claims should be paid as 
in-network. 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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for dates of service November 19, 2022, to November 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Stelara first.  
 
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 Entyvio. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Stelara 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less 
effective and/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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health services provided from March 19, 2022, through 
April 15, 2022. 
 
You asked the Plan to pre-approve the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that these are non-covered services because this is not deemed a 'medical necessity' by 
the payer. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Documentation was not provided by the Plan to verify what services were paid 
or denied. Therefore, we decided that the Plan has to pre-approve the home health services provided from 
March 19, 2022, through April 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography 
(PET); metabolic evaluation (78608). 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records.  The 
Plan denied your request. The Plan says the records do not indicate that the enrollee meets the diagnostic 
criteria for both Alzheimer's Disease and frontotemporal dementia.  
 
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 PET scan. Our physician reviewer 
found the enrollee is only noted to have a mild cognitive impairment (MCI). They are not noted to meet/satisfy 
diagnostic criteria for either left alone both AD, or FTD. In as much the base requirement of the NCD for 
coverage would not be met at this time. Therefore, the service is not eligible for coverage. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the brain imaging, positron emission tomography (PET); metabolic evaluation (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64483). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 3 months of 50% pain relief is required in order for a block to be 
successful. The request is for the same level and approach. Therefore, the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care for the vascular embolization 
or occlusion (37242). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the procedure is not on the Centers for Medicare & Medicaid Services 
(CMS) inpatient only list. The Plan states the preoperative clearance and comorbid conditions suggest that the 
procedure could initially be performed on an ambulatory/observation basis. The Plan states there is no need to 
prospectively approve the inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that the admitting physician 
reasonably expects that your necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care for the vascular embolization or occlusion 
(37242).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and related supplies. 
 
You asked the Plan to pre-approve a wheelchair and related supplies. You say that the requested wheelchair 
and related supplies are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage of a wheelchair and related supplies have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and related supplies are being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair and related supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 31, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met.  
 Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided 
that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service October 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic continuous CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that the request for a CGM and 
supplies are necessary for the enrollee to check blood sugar levels. The Plan denied your request. The Plan says 
that this benefit limitation has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not include proof the benefit limitation for the CG has been 
exhausted. Therefore, we decided that the Plan has to pre-approve a therapeutic continuous CGM.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and ultrasound therapy (97035) 
provided on December 28, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the services in this case are medically 
appropriate and necessary for the enrollee. The Plan denied your request. The Plan says prior authorization has 
not been 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 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 the office visit (99213) and ultrasound therapy 
(97035) provided on December 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee does meet medically 
necessity based on Medicare guidelines for the tilt and recline. The Plan denied your request. The Plan says 
that upgraded electronics exceed the enrollee's need and is not reasonable and necessary per Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing basic daily activities. The reviewer found that the 
enrollee cannot perform pressure relief independently due to weakness and requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The reviewer found that the enrollee also 
requires power elevating leg rests for positioning of lower extremities. The complexity of the enrollee's seating 
and positioning needs necessitates a more complex Group 3 power wheelchair base. The expandable controller 
with harness and electronic connection are necessary to operate the Group 3 power wheelchair base and the 
three power options, including, tilt, recline and elevating leg rests, via a joystick. Therefore, the reviewer found 
that the upgraded electronics, made up of an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311), are 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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tdap vaccination you received on August 22, 2022. 
 
You asked the Plan to pay for Tdap vaccination. You say that you were in the office and were told you needed 
this vaccination because it had been ten years since you had one. You said that coverage of this vaccine was not 
discussed. The Plan denied your request. The Plan says this vaccination is not covered under your medical 
benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tdap vaccination. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tdap vaccination. 
Therefore, we decided that the Plan does not have to pay for Tdap vaccination you received on August 22, 
2022.  
 
Benefits for Tdap vaccination may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.