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

 
We decided that the Plan does not have to pre-approve a positioning back cushion (E2620), a custom seat 
cushion (E2609), and wheelchair transfer handles (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee requires the requested 
wheelchair and all requested accessories due to his lack of mobility. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for approval of the requested wheelchair accessories. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that accessories including custom fabricated seat or back cushions meet criteria if 
there is a history of or current diagnosis of a pressure ulcer in the area of contact with the seating surface or if 
there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a 
functional weight shift. Additionally, it may be covered if the enrollee has a significant postural asymmetry and 
a licensed/certified medical professional, such as a physical therapist or occupational therapist, has noted a 
prefabricated seating system is not sufficient to meet the enrollees seating and positioning needs. There is no 
indication the enrollee has any pressure injuries to the skin that would necessitate a custom seat cushion and 
there is no documentation of abnormal posture or positioning that would require a specialized back cushion. 
Additionally, the documentation doesn't support the enrollee would be able to use transfer handles due to 
weakness. In this case, the requested accessories are 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positioning back cushion (E2620), a custom seat cushion (E2609), and 
wheelchair transfer handles (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84480 billed for date of service 
December 28, 2022.   

You asked the Plan to pay for procedure codes 84436 and 84480. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for codes 84436 and 84480 
is bundled into payment for codes 84439 and 84481. 
 
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 
84436 and 84480 are column II codes to column I codes 84439 and 84481 with a modifier indicator of 0. The 
column II codes are therefore not payable. 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 84436 and 84480 billed 
for date of service December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring System (K1024, K1025). 
 
You asked the Plan to pre-approve the Koya Dayspring System. You say that please review the attached 
records and clinical evidence and reconsider the decision to deny coverage. The Plan denied your request. The 
Plan says medical studies haven't proven this service/item is helpful for the treatment of the enrollee's health 
problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is insufficient evidence in the medical literature to demonstrate 
that the Koya Dayspring Active Compression Garment System is an effective treatment modality for the 
diagnosis of lymphedema, providing lasting relief, as compared to other treatment modalities. The device has 
Bluetooth technology and a companion application that exceeds medical need. Based on this information, we decided that Medicare rules for coverage of the Koya Dayspring System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Koya Dayspring System (K1024, K1025).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomepra Mag Cap 40mg Dr. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Esomepra Mag Cap 40mg Dr.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoCel allograft (20930). 
 
You asked the Plan to pre-approve OsteoCel allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the OsteoCel allograft in the setting 
of a lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 OsteoCel allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found OsteoCel allograft is experimental when used as bone graft in spinal surgery. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OsteoCel allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve OsteoCel allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and topical 
application of fluoride varnish (D1206) provided on November 22, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test and topical application of fluoride varnish. You 
say that most of the dentists are out-of-network. The Plan denied your request. The Plan says these services are 
not included on your benefit plan, and therefore, are not covered services. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431) and topical application of fluoride varnish (D1206) provided on 
November 22, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) 
visits (G0151).  
 
You asked the Plan to pre-approve additional home health 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found based 
on the available records, the enrollee has been receiving therapy services since June 19, 2023, and he reports 
that he is maintaining overall function with therapy. After the physical therapy treatments already provided 
plus the three additional visits approved, the records do not support that the complexity of the enrollee's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate 
at this point. No medical notes from the enrollees treating physician are provided documenting an order or 
need for additional skilled therapy services. After completion of the recently approved additional therapy, 
follow-up with the enrollee's physician may be appropriate to evaluate the need for additional treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) additional home health physical therapy (PT) visits (G0151).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 7, 2022, billed 
with codes 84492, 81401, 81403, 81404, 81405, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that the gene panel evaluates 56 genes. The 
Plan denied your request. The Plan says the analyte being tests must be submitted on the claim. 

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 7, 2022, billed with codes 84492, 81401, 81403, 81404, 81405, and 81406.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided documentation did not reveal any unstable condition or high-
risk factors that would expect hospital care needs to cross 2 midnights related to this procedure. Observation 
status appears to be most appropriate following this planned procedure with the option to upgrade as needed. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 21, 2022. 
 
You asked the Plan to pay for the office visit. You say that you go to the VA every six months and this has 
always been paid by your insurance. The Plan denied your request. The Plan says this services was rendered by 
a provider who is not under contract with the health Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare explicitly excludes VA facilities from 
participating in Medicare. 
 
We looked at the file and Medicare rules. Medicare excludes VA facilities from participating in Medicare. You 
can contact the VA to ask why you are being billed for services rendered at a VA facility if you are  
VA-eligible. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for an office visit provided on  
December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit tie down system (K0108). 
 
You asked the Plan to pre-approve the transit tie down system. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transit tie down system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the transit tie down system (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (83520, 82306, 82533, 82607, 82627, 
82670, 82728, 82746, 83001, 83002, 83003, 83036, 83540, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 
84439, 84481 and 80061) billed for date of service February 6, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says they have agreed to approve and pay for 
code 80050; however, there is no evidence that these other codes were specifically requested by the enrollee's 
treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the physician order shows that only a Standard Wellness Panel was requested. The Plan has 
already approved and agreed to pay for code 80050 on this claim, which is defined in the CPT code Manual as, 
general health panel: this panel must include the following: Comprehensive metabolic panel (80053) Blood 
count, complete (CBC), automated and automated differential white blood cell count (WBC) count (85025 or 
85027 and 85004) or Blood count, complete (CBC), automated (85027) and appropriate manual differential 
WBC count (85007 or 85009) and Thyroid stimulating hormone (TSH) (84443). This means that the code that 
has already been approved encompasses and includes many of the other services provided. It is not clear how 
the other codes billed are medically necessary, and there is no evidence that these services were requested by 
the enrollees treating physician. In addition, it is inappropriate to report multiple laboratory services when a 
single specimen is tested for multiple genes, molecular multianalyte assays, multianalyte assays with 
algorithmic analysis, or proprietary laboratory analyses. Only a single code to report the panel, such as 80050, 
would be appropriate. Therefore, we decided that the Plan does not have to pay for laboratory services (83520, 
82306, 82533, 82607, 82627, 82670, 82728, 82746, 83001, 83002, 83003, 83036, 83540, 83735, 83970, 84144, 
84146, 84270, 84305, 84403, 84439, 84481 and 80061) billed for date of service February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator for nine months. 
 
You asked the Plan to pre-approve the continued use of a home ventilator for nine months. You say that the 
enrollee has been on a ventilator since 2019 with the Plan authorizing it for the past year. You also say that the 
medical records support the necessity for the home ventilator.  The Plan denied your request. The Plan says 
based on Medicare guidelines, the request for continued use of a device to assist with breathing does not meet 
the requirements for approval. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 continued use of a home ventilator 
for nine months. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
compliance in use of the device is excellent. The device is being used in the AVAPS-AE mode, which can be 
provided with BiPAP. There is no diagnosis of COPD, thoracic disease, or neuromuscular disease. The records 
do not show that BiPAP with AVAPS-AE has been tried and failed as an outpatient. Medicare does not cover a  
home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. 
 
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 continued use of a home ventilator for 9 months. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continued use of a home ventilator for 
nine months.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for tooth #22 and #27 (D2950). 
 
You asked the Plan to pre-approve the core buildup services. You say that a fixed option is ideal for this 
enrollee and would allow for easier care. The Plan denied your request. The Plan says core build up procedures 
are allowed when there is insufficient tooth strength and retention for the crown procedure. Teeth #22 and 27 
do not show extensive damage from decay or fracture that would require a core build up to retain a crown. 
 
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. The Plan covers the core buildup services when the services are medically necessary and reasonable.  
 
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 core buildup services. Our reviewer 
says that the criteria for coverage have not been met.  Our physician reviewer found core buildups are indicated 
when there is significant breakdown of the coronal structure of the tooth which cannot provide adequate 
support and retention of a crown restoration.  The documentation provided does not indicate that there is 
significant coronal breakdown of the coronal structures of tooth #22 and #27 to warrant core buildups. 
 
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 core buildup services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core buildup for tooth #22 and #27 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external continuous glucose monitor (CGM) 
transmitters (A9277). 
 
You asked the Plan to pre-approve external CGM transmitters. You say that you are running out of 
transmitters. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies such as external transmitter A9277 are 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of external CGM transmitters have not been met. Therefore, we decided that the Plan does not have to 
pre-approve external continuous glucose monitor (CGM) transmitters (A9277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the side guards (K0108). 
 
You asked the Plan to pre-approve the side guards. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the side guards are a convenience item and 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the side guards have not been met. Therefore, we decided that the Plan does not have to pre-
approve the side guards (K0108).