Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81226 billed for date of service March 15, 2023. 
 
You asked the Plan to pay for procedure code 81226. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that the provided records do not support the code billed. 
 
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 
code 81226 is: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene 
analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN). 
 
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 procedure code 81226. Our reviewer says that procedure 
code 81226 does meet criteria for payment in this case. Our reviewer found that you reported diagnosis code 
F33.2 Major depressive disorder, recurrent severe without psychotic features. After review of documentation 
and Medicare guidelines, diagnosis code F33.2 supports medical necessity for CPT 81226. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 81226 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 81226 billed for date of service March 15, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro brace. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says experimental and investigational 
procedures are not covered by Medicare. 
 
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 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 
patient's condition or in widespread use for this patient's condition based on scientific evidence. Our reviewer 
found that there is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term 
outcomes for this patient. Our physician reviewer also found that 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 brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro brace (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 4, 2023. 
 You asked the Plan to pay for the lab testing. You say that the testing meets all the requirements for coverage. 
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. The lab assessment did not demonstrate that the analytical and 
clinical validity, and clinical utility meets the Medicare reasonable and necessary requirement. Per the DEX 
Diagnostics Exchange, the test at issue is not a covered test. Based on this information, we decided that 
Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing billed for date of service April 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 your medical 
conditions are being managed on an outpatient basis, including diabetes mellitus type II. You are independent 
with your daily activities. There is no documentation for a need for skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Horizant. 
 
You asked the Plan to pre-approve the medication. You say that Horizant is medically 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 Horizant.   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been in the acute setting 
for 60 days and has failed to improve back to their baseline. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation because you need dialysis three times per week. You also say that it is unsafe for you to drive 
yourself to these appointments. The Plan denied your request. The Plan says the service is a covered benefit, 
but the request exceeds limits set in the subscriber agreement. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression Garment 
System (K1024 and K1032). 
 
You asked the Plan to pre-approve the Koya Dayspring Active Compression Garment System. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items are considered 
experimental. 
 
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 Koya Dayspring Active 
Compression Garment System. Our reviewer says that the requested items are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided documentation did not 
clearly describe any wounds in his extremities or any other indication to justify a compression device. Also, the Koya Dayspring has no high-quality literature to support its use over standard compression devices at this time. 
 
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 Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression 
Garment System (K1024 and K1032).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 13, 2023. 
 
You asked the Plan to pay for code 99285. You say that this visit was an emergency and was medically 
necessary. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 12001 
provided on January 13, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for code 99285 billed for date of service 
January 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from April 
21, 2021, to April 30, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you initially billed this claim in September of 
2021.  That claim didn't have any billing errors but was missing the PDPM code. You initially billed it with an 
unknown code but replaced it with code ZZZZ1 on your resubmission. The Plan denied your request. The Plan 
says you billed the incorrect default PDPM code. 
 
The Plan must follow Medicare rules. Medicare rules say that the correct default PDPM code is ZZZZZ.  
Instead, you billed code ZZZZ1 in error.  Code ZZZZ1 is not a valid code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services provided from April 21, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device. 
 
You asked the Plan to pre-approve a Volara device. 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 Volara device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Volara device is not medically necessary. There is inadequate evidence that this device is 
as, or more, effective than other devices in achieving airways clearance. Medicare does not cover use of the 
Volara in the outpatient setting.  
 
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 Volara device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara system-high frequency oscillation lung expansion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyprolis. 
 
You asked the Plan to pre-approve Kyprolis. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met, 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Kyprolis. Our reviewer says that 
Kyprolis is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kyprolis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kyprolis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the platelet rich plasma injection provided on  
March 29, 2023. 
 
You asked the Plan to pay for the platelet rich plasma injection. You say that the platelet rich plasma injection 
was medically necessary. The Plan denied your request. The Plan says the platelet rich plasma injection does 
not meet the Medicare coverage criteria. 
 
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 platelet rich plasma injection. Our 
reviewer says that the requested platelet rich plasma injection is not considered medically reasonable and 
necessary. Our physician reviewer found that the documentation does not support that platelet rich plasma 
injections are medically necessary and they do not fulfill criteria outlined for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the platelet rich plasma injection have not been met. Therefore, we decided that 
the Plan does not have to pay for a platelet rich plasma injection provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids and the sales tax provided on July 12, 2023. 
  
You asked the Plan to pay for the hearing aids and the sales tax. You say that the provider should be accepted 
because they provide free certified hearing test by a licensed examiner and charges almost half as much as the 
hearing doctor would charge. The Plan denied your request. The Plan says the provider was out-of-network, 
and the sales tax is not a covered service. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by network providers.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids and the sales tax have not been met. Specifically, the provider was out-of-network, 
and the sales tax is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the 
hearing aids and the sales tax provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-adjunctive, non-implanted continuous glucose monitor 
(CGM) or receiver (E2103). 
 
You asked the Plan to pay for a non-adjunctive, non-implanted CGM or receiver. You say that the enrollee 
needs the monitor in order to read their glucose. You also say that the enrollee got approved for the sensors but 
not for the monitor. The Plan denied your request. The Plan says under Medicare guidelines, this request is not 
medically necessary because the records do not show that the device needs to be replaced due to loss or 
damage, and the age of the device has not reached its reasonable lifetime limit.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a non-adjunctive, non-implanted CGM or 
receiver. Our reviewer says that the coverage criteria for a CGM requires insulin use or low blood glucoses 
(BGs). Our physician reviewer found this enrollee is not taking insulin and is not having low BGs that we are 
told of. The enrollee is on a medication that does not typically cause low BGs. Our reviewer also found that we 
are not told why a finger-stick meter would not suffice. 
 
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 non-adjunctive, non-implanted CGM or receiver have not been met. 
Therefore, we decided that the Plan does not have to pay for a non-adjunctive, non-implanted continuous 
glucose monitor (CGM) or receiver (E2103).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan requires authorization prior to receiving care from out-of-network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 23, 2023, by an out-of-network 
(OON) provider.