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

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. 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 a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 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. 
 
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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, of 22 or more drug classes 
(G0483) provided May 30, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please reconsider your decision and process 
the payment on this claim. The Plan denied your request. The Plan says under Medicare rules, the number of 
definitive urine drug classes requested are 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with chronic low back pain due to spondylosis, was being treated with 
hydrocodone, Tylenol, and gabapentin. Definitive drug testing, of 22 or more drug classes (G0483) was 
requested. However, the documentation did not support definitive testing, particularly for 22 drug classes; 
considering much less classes were being prescribed to the enrollee. The presumptive urine drug screening was 
consistent with opioids and there was no unexpected urine drug screen results or report of unusual behavior or 
suggestion of drug abuse/misuse to justify definitive drug testing. Therefore, this enrollee does not meet the 
coverage criteria for such testing as it is excessive.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing, of 22 or more drug classes (G0483) provided May 30, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 24, 2023, to July 28, 
2023, billed with procedure codes 93228 and 93229. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 93228 and 93229 is external mobile cardiovascular 
telemetry with electrocardiographic (ECG) recording, concurrent computerized real time data analysis and 
greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient 
selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation 
with report by a physician or other qualified health care professional, and external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 
24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected 
events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection 
and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data 
reports as prescribed by a physician or other qualified health care professional. 
 
We asked our coder 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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that code 93228 is not supported. The 
record does not contain documentation that external mobile cardiovascular telemetry with concurrent analysis 
an ECG triggered event transmission was performed on the dates of service in question. Code 93229 is not 
supported. The record does not contain documentation for the technical component of external mobile 
cardiovascular telemetry with concurrent analysis and ECG triggered event transmission for the dates of 
service in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on July 24, 2023, to July 28, 2023, billed with 
procedure codes 93228 and 93229.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 (Factor V Leiden) genetic testing. 
 
You asked the Plan to pre-approve F2 and F5 tests. You say that you are appealing this denial. The Plan denied 
your request. The Plan says these tests are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 gene testing are non-covered except in 
pregnant enrollees.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 tests have not been met. Therefore, we decided that the Plan does not have to pre-
approve F2 and F5 (Factor V Leiden) genetic testing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy 
 
You asked the Plan to pre-approve the therapy services. You say that aquatic therapy is medically necessary. 
The Plan denied your request. The Plan says aquatic therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the proposed water therapy is not medically necessary per standards 
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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic therapy
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee desperately 
needs this power equipment. You also say that without all the requested functions, this enrollee will continue to 
be high risk for falls, pressure injuries, and dependence on others for activities of daily living. The Plan denied 
your request. The Plan says the enrollee does not have medical need for multiple power options included with a 
group 3 power wheelchair. The Plan also says the requested items cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has cerebral palsy. She has a history of playing golf 2-3 
times per week. After a fall with spinal cord compression, she has good strength in her lower extremities but 
has considerable anxiety about falling. She is able to prepare meals independently. Per L33789, the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0108).
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 you are requesting reconsideration for 
the denial of an LTACH admission based on complex medical necessity. The Plan denied your request. The 
Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 being treated for multiple medical conditions including 
intravenous antibiotics, wound care and dialysis. There does not appear to be any services that would be 
provided at an LTACH that the enrollee is not able to receive currently. The enrollee's condition has stabilized 
and they do not require the daily care of multiple disciplines. In addition, it doesn't appear that the enrollee will 
require inpatient level services that would meet or exceed 25 additional days. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 15, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services to regain strength and 
independence before returning home. The Plan denied your request. The Plan says you do not meet the 
requirements for approval of the requested IRF services.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. Medically necessary services can be 
provided in a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686), provided on July 5, 2023. 
 
You asked the Plan to pay for the hip orthosis. You say that the item 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 relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication this item was discusses, needed, or ordered by the treating physician in the clinical records submitted. 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 the hip orthosis 
(L1686), provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain/ceramic (D6245) for tooth #7, #8 and 
#9 and a retainer crown-porcelain/ceramic (D6740) for tooth #5, #6, #10 and #11.  
 
You asked the Plan to pre-approve the dental services. You say that your bridge has been broken for two 
months. You say you are a diabetic and in pain and this is affecting your food intake because the bridge keeps 
moving. The Plan denied your request. The Plan says the request does not meet the criteria for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 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 pontic-porcelain/ceramic (D6245) for 
tooth #7, #8 and #9 and a retainer crown-porcelain/ceramic (D6740) for tooth #5, #6, #10 and #11.  Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found following the 
Plan's coverage criteria for fixed prosthodontics, the placement of a fixed prosthetic appliance will only be 
considered for those exceptional cases where there is a documented physical or neurological disorder that 
would preclude placement of a removable prosthesis. The provided records in this case do not document a 
physical or neurological disorder that precludes the use of a removable prosthesis. Therefore, criteria for 
coverage are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the requested dental services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic-porcelain/ceramic (D6245) for tooth #7, #8 and #9 and a retainer 
crown-porcelain/ceramic (D6740) for tooth #5, #6, #10 and #11.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the right leg. 
 
You asked the Plan to pre-approve the MRI. You say that you need the MRI to determine if there are cancer 
cells in the bones of your leg. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found the enrollee has a history of lung cancer and 
non-Hodgkins lymphoma. There is no dedicated x-ray series of the right femur and no description of the 
features of this incidental bone lesion. Prior to authorizing an MRI a thorough plain film series of the right 
femur needs to be done. The next step if the lesion is a true lesion would be a bone scan in order to evaluate the 
metabolic activity of this lesion. 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the right leg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam, (D0150), and a comprehensive 
series of radiographic images (D0210) provided on August 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this second opinion. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 10, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam, (D0150), and a 
comprehensive series of radiographic images (D0210) provided on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU system) (E0650, E0673, 
E0666, 97760) provided on May 11, 2023, to May 30, 2023. 
 
You asked the Plan to pay for the vascular compression unit (VCU system) (E0650, E0673, E0666, 97760). 
You say that the items were medically necessary. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the vascular 
compression unit (VCU system) (E0650, E0673, E0666, 97760) provided on May 11, 2023, to May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 5, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says experimental services are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on April 5, 2023.