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

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you are having Achilles surgery and this 
knee scooter will help with mobility and function. The Plan denied your request. The Plan says the item is not 
covered by Medicare or the plan. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. This item is available to the general public and would be helpful even to those who 
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute, 
lower leg platform, with or without wheels (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that without proper treatment, the 
lymphedema can cause severe issues. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for test code G0452-26-59 provided on March 16, 2023. 
 You asked the Plan to pay for G0452-26-59. You say that the modifier requirements have been met due to the 
distinct nature of the analytes used. The Plan denied your request. The Plan says the record does not support 
that this procedure was distinct and separate from the other services performed. 
 
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 G0452 is a column II code to column I codes 81270, 81219, and 
81339; however, G0452 was billed with a modifier.  
 
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 G0452-26-59. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the laboratory report does not support criteria have been met for 
separate payment for interpretation of the tests that were performed. Code G0452 is used to report a medically 
necessary interpretation and written report of a molecular pathology test, above and beyond the report of lab 
results. This code is intended to be used by more specialized providers such as pathologists, molecular 
pathologists, or geneticists who process the samples, interpret the results, and create a written report. The 
review of the test results is considered to be part of the medical decision-making key component and is not 
separately billable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0452-26-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for test code G0452-26-59 provided on March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Minuteman G5 MIS fusion plate. 
 
You asked the Plan to pre-approve the Minuteman G5 procedure. You say that the denial for this procedure is 
unwarranted and unsupported by the enrollee's current medical status and is inconsistent with currently 
accepted medical practice. The Plan denied your request. The Plan says the Minuteman device not medically 
necessary. The Plan says the device is not approved for use in a stand-alone procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman G5 procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do 
not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition as discussed above. According to the Food and Drug Administration (FDA), the 
HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for 
use at a single level in the non-cervical spine (T1-S1). 
 
In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability 
have not been documented and/or met in this case. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested arthrodesis using the 
Minuteman G5 MIS fusion plate 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 the Minuteman G5 procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the Minuteman G5 MIS fusion plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided from January 11, 2022, to February 
2, 2022. 
 You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the lab services are 
not covered for the billed diagnosis. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided from January 11, 2022, to February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services (81528) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve laboratory services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee must use network providers to get her medical care and 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
laboratory services (81528) to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high complexity (99285) provided on March 11, 2023. 
 
You asked the Plan to pay for an emergency department visit. You say that you request reconsideration and 
have submitted medical records for review. The Plan denied your request. The Plan says code 99285 remains 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 an emergency department visit. Our reviewer says that the 
service does not meet criteria for approval of payment. Our reviewer found although report supports 
comprehensive history and exam, procedure report does not support criteria for procedure code 
reported.  Documentation submitted does not include documentation to support high severity and pose an 
immediate significant threat to life or physiologic function. Medical records include radiology and 
electrocardiogram (ECG) services. In this case, there is a more appropriate code that should be reported for 
service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit for the evaluation and management of a 
patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's 
clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical 
decision making of high complexity (99285) provided on March 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous (IV) insulin therapy (OIVIT) 
services provided on June 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare rules, the requested OIVIT services are not medically reasonable and necessary, and therefore are not covered. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient intravenous (IV) insulin therapy (OIVIT) services provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the AngelMed Guardian System. 
 
You asked the Plan to pre-approve the AngelMed Guardian System. You say that the AngelMed Guardian 
System is medically necessary. The Plan denied your request. The Plan says the AngelMed Guardian System 
is considered experimental and investigational because the effectiveness has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the AngelMed Guardian System. Our 
reviewer says that the requested AngelMed Guardian System is not considered medically reasonable and 
necessary. Our physician reviewer found that an exhaustive review of the current medical literature pertaining 
to the AngelMed Guardian System confirms several observational studies suggesting clinical benefit. While the 
clinical studies led to the Food and Drug Administration (FDA) approval, the AngelMed Guardian system remains the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. 
 
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 AngelMed Guardian System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the AngelMed Guardian System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, E0973, 
E1028, E2365) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are asking for a rural 
exception for this authorization. The Plan denied your request. The Plan says the enrollee must receive services 
from a network provider. There are in-network providers in the enrollee's area that can assist with the 
equipment she needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and accessories (K0823, E0973, E1028, E2365) to be provided by an out-of-network 
(OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for code 99285 for date of service August 3, 2022. 
 
You asked the Plan to pay for code 99285. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that Evaluation and Management codes are not covered for this specialty or 
provider type. 
 
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. Review of the file shows that the Plan states that Evaluation and Management 
codes are not covered for this specialty or provider type. However, the documentation provided did not include 
a Medicare rule to support this denial. No other denial rationale was provided. The Plan did not substantiate 
their denial. Therefore, we decided that the Plan has to pay for code 99285 for date of service August 3, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH care.  The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require any services from an LTACH that are not already 
available and covered at the current facility.  
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 You asked the Plan to pre-approve home health services. You say that you are appealing the Plan's 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The enrollee's wounds are superficial, and the wound care 
being provided is not complex. The enrollee has a caregiver available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health care.
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 the enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says the enrollee's records do not show the need for 
requiring a rehabilitation physician at least three times a week or the need for an intensive team for care. The 
Plan says that the services needed may be provided safely in a lower level of care.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your condition does not meet the Medicare guidelines for admission to 
an IRF.  
 
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. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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.