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

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that you need additional oxygen equipment 
because the portable tanks you have now eights 9 1/2 pounds each. Trying to carry 9 1/2 pounds with one hand 
and balance with your cane is very dangerous. The Plan denied your request. The Plan says the enrollee 
currently has the standard item that meets their medical needs. Duplicate items are not covered by Original 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an oxygen homefill system and 2 portable oxygen D-cylinder gaseous tanks. The 
portable oxygen D-cylinder gaseous tanks serve the same purpose as the oxygen equipment. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that you need the ventilator. The Plan denied your 
request. The Plan says your needs could be met with another type of device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the records do not support the medical necessity of the ventilator. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee is being treated with bilevel positive airway pressure (BiPAP). The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured 
pressure support (AVAPS) capability and failure of such a device has not been documented. The Plan has 
indicated coverage for such a device is available upon request. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with 
AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an alignable system below the knee (L5910). 
 
You asked the Plan to pre-approve an alignable system. The Plan denied your request. The Plan says that the 
notes do not show why the enrollee's current alignable system (L5910) cannot be used. The Plan also says the 
alignable system is not reasonable and necessary for the approved prosthesis. 
 
The Plan follows Medicare rules. Medicare rules say that claims involving the replacement of a prosthesis or 
major component (foot, ankle, knee, socket) must be supported by a new treating practitioner's order and 
documentation supporting the reason for the replacement. 
 
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 alignable system. Our reviewer says 
that an alignable system is medically reasonable and necessary for the enrollee. Our physician reviewer found 
the facts establishing the enrollees routine use of their prosthesis, and the obvious expected need for 
occasional replacement, is adequately documented in the prosthetist notes and corroborated by the medical 
doctor in their last Annual Wellness Visit. Specific to this case, it is documented that the enrollee has had a 
change in his condition, objectified by the need for 20 sock ply to maintain a proper socket fit. Our reviewer 
found this is excessive and puts the enrollee at risk of skin breakdown. Our physician reviewer found that 
further, a socket's alignable system specifically is not usually recycled between sockets precisely because it is 
laminated directly into the structure of the previous socket. 
 
 
 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 alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve an alignable system below the knee (L5910).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease 
Bundle provided on October 15, 2022. 
 
You asked the Plan to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle. You say 
that you would like the Plan to reconsider their denial of 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 for this Medicare covered diagnostic test. Based on this information, we decided that Medicare 
rules for coverage of the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant Reveal Post-Surgery Minimal 
Residual Disease Bundle provided on October 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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the Medicare coverage criteria for inpatient rehabilitation admission. 
 
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 you are medically stable and does not need physician supervision at least 3 times per 
week. You do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week as you would not likely tolerate this level of therapy. The complexity of your nursing, rehab, and 
medical, needs (combined complexity) does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 26, 
2022. 
 You asked the Plan to pay for procedure code 99284. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service August 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee just completed therapy with Evenity. You 
also say that Prolia is the recommended follow-up treatment. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the case file does not contain documentation 
of trial and failure of zoledronic acid. The reviewer found that the documentation does not support that 
zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this 
case. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6199 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code A6199. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A6199 is considered bundled/excluded from payment. 
 
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 A6199 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A6199 is not separately payable/excluded from payment. Based on this information, we 
decided that Medicare rules for coverage of procedure code A6199 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code A6199 billed for date of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eCoin neuromodulation therapy. 
 
You asked the Plan to pre-approve eCoin procedure. You say that the requested treatment is the only Food and 
Drug Administration (FDA) approved tibial stimulation therapy for the treatment of the enrollee's condition. 
You also say that the requested treatment is medically necessary for the enrollee. The Plan denied your request. 
The Plan says the requested treatment 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 eCoin procedure. Our reviewer says 
that the requested eCoin procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found found the requested eCoin procedure is considered experimental/investigational. The 
reviewer found that studies that have been completed have been prospective with small enrollments. The reviewer found that eCoin is not considered as an acceptable treatment option for the enrollee's condition. 
Therefore, the reviewer found that the requested procedure is 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 eCoin procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eCoin neuromodulation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary. The Plan 
denied your request. The Plan says you continued stay at acute hospital until you are stable enough for 
discharge to a lower level of care has not been denied. 
 
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 you were admitted with intracranial hemorrhage with herniation. The record indicates 
that you are critically ill, has ongoing medical issues and still requires acute care services.  You continue to 
receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  
The elements of the coverage rules are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on October 1, 
2022. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal testing (81479) provided on October 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical research laboratory services provided March 31, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are receiving incorrect bills from the 
facility for services and the facility staff is not responding to the requests to correct the inaccuracy. The Plan 
denied your request. The Plan says services that are for a clinical research program, must be billed to Original 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for the laboratory services as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Services that are for a clinical research program, 
must be billed to Original Medicare. Therefore, we decided that the Plan does not have to pay for the clinical 
research laboratory services provided March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sling provided on November 2, 2022. 
 
You asked the Plan to pay for the sling. The Plan denied your request. The Plan says the incorrect place of 
service was billed. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the sling provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 billed for date of service 
September 28, 2022. 
 You asked the Plan to pay for procedure codes 99285 and 93010. The Plan denied your request. The Plan says 
payment for codes 99285 and 93010 is bundled into payment for code 99152. 
 
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, we have confirmed that codes 
99285 and 93010 are column II codes to column I code 99152. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99285 and 93010 billed for 
date of service September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology/oncology services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that you were told when you enrolled that you 
could continue to see the providers at this facility. You state that you have anxiety and changing to a new 
doctor is not an option for you. The Plan denied your request. The Plan says you do not have coverage for 
OON services unless provided in an emergency/urgent situation, or when the Plan's network does not have the 
type of provider you require. There are several in-network providers who can assume your care. 
 
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. You are not undergoing active treatment 
based on the records submitted. 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 dermatology/oncology 
services to be provided by an out-of-network (OON) provider.