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

 
We decided that the Plan has to pre-approve Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the medical criteria for a CGM have not been met. 
The Plan denied your request. The Plan says that the enrollee would benefit from this procedure. 
 
The Plan must follow 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 pre-approve a CGM. Our reviewer says that a CGM 
is medically necessary. Our physician reviewer found the enrollee is now being prescribed insulin. This CGM 
will likely help adjust doses for the enrollee. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-approve 
Dexcom G7 continuous glucose monitor (CGM).  
 
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 pay for the evaluation and management services coded as 99223 
performed on April 6, 2023. 
 
You asked the Plan to pay for 99223. You say that 99223 should be covered because it is supported in the 
records. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the records. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 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 99223. Our reviewer says that 99223 is not 
supported in the record. Our reviewer found documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of high level. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services coded as 99223 performed on April 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that this procedure would help the 
enrollee with back pain. The Plan denied your request. The Plan says there are not enough studies on Vertiflex 
Superion to show it is safe and effective. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found The Vertiflex device is experimental, and 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 a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
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 is receiving acute care in an approved facility. There are no specific 
treatments the enrollee would receive at the LTACH that they are currently not receiving. There are no clear 
indications for LTACH services. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in extreme pain after having surgery and 
would benefit from the services received in an IRF. The Plan denied your request. The Plan says you do not 
meet the criteria 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 you are medically stable except your pain. There are no acute rehab nursing needs 
identified or documented. Document does not support medical necessity for admission to an IRF. Your rehab 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary and 
will provide the enrollee with the ability to regain maximum function. The Plan denied your request. The Plan 
says the enrollee may stay in the hospital where they are now to finish their hospital treatments. 
 
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 appears to be more stable and requires only short-term additional acute 
care hospital services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a dermatology office visit provided out-of-area (OOA) on April 6, 
2023. 
 
You asked the Plan to pay for the OOA dermatology office visit. You say that the medical records provided 
support that the services were medically necessary. The Plan denied your request. The Plan says that the 
clinical records do not support that the services provided were urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 OOA dermatology office visit. Our 
reviewer says that the criteria for OOA coverage have been met. Our physician reviewer found the enrollee 
could not have foreseen requiring the services prior to leaving their service area. The care provided was 
medically necessary. The enrollee developed acute severe contagious disease which required immediate 
treatment, and it would not have been medically reasonable to delay the services until the enrollee returned to 
their service area.  
 
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 OOA dermatology office visit have been met. Therefore, we decided that 
the Plan has to pay for a dermatology office visit provided out-of-area (OOA) on April 6, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 8, 2023, billed with 
codes 87481, 87651, 87641, 87500, 87640, 87653, 87798, and 87551. You asked the Plan to pay for the genetic testing billed. You say that medical records were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code 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 
May 8, 2023, billed with codes 87481, 87651, 87641, 87500, 87640, 87653, 87798, and 87551.
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 would benefit from this care. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an LTACH 
admission, and needs can be met in the current setting. 
 
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 services can safely be provided at the current facility until the enrollee is more stable 
and appropriate for transfer to a different level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips (A0100). 
 You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says your 
benefit plan does not cover more than 40 one-way trips per plan year. 
 
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 40 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation trips. 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 20 additional routine transportation trips (A0100).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided 
on March 21, 2023. 
 
You asked the Plan to pay for the ambulance service. You say that you did not know if you refused transport 
that you would be charged a fee. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport provided on March 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9480 billed for date of service March 22, 
2022, to May 5, 2022. 
 
You asked the Plan to pay for procedure code S9480. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9480 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9480 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9480 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9480 billed for date of service March 22, 2022, to May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve upgraded pylon. We decided that the Plan does not have to pre-
approve a vacuum suspension system.  
 You asked the Plan to pre-approve a vacuum suspension system and upgraded pylon (L5781, L5988).. You say 
that the services are necessary. The Plan says that based on the documentation provided, coverage criteria have 
not been met. 
 
We decided that the Plan has to pre-approve upgraded pylon.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 upgraded pylon. Our reviewer says that 
the services are medically necessary. Our physician reviewer found given the fact that he is at least a K3 level 
ambulator who is very active and spends a considerable amount of his day walking and standing on his feet as a 
cook, he would benefit from an upgraded pylon to reduce the torsional forces placed on his residual limb. The 
upgraded pylon is 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 upgraded pylon have been met. Therefore, we decided that the Plan has to pre-
approve upgraded pylon.  
 
We also decided that the Plan does not have to pre-approve a vacuum suspension system. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 vacuum suspension system. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found while it is 
understandable that a vacuum assisted suspension system is being requested, there is a lack of medical 
literature clearly supporting that it is superior to standard suspension systems. Therefore, the requested vacuum 
suspension system is 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 a vacuum suspension system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vacuum suspension system. 
 
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 DecisionDx-SCC test billed for date of service February 
28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test results inform treatment decisions. The 
Plan denied your request. The Plan says the billed code is not supported. 
 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 records do not show that the test reasonable and necessary 
requirements were met. A review of the claim does not show that the required unique identifier was reported. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test billed for date of 
service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the enrollee needs the injection as soon as possible 
to maintain their health. The Plan denied your request. The Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS only covers FDA approved monoclonal 
antibodies directed against amyloid for the treatment of AD when furnished in accordance with Section B 
under coverage with evidence development. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Leqembi (J0174).
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 is ready for transfer to the 
LTACH. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 appears to be improving with current treatment and should only short-
term additional acute care hospital services that can be safely provided at the current facility until more stable 
for transfer to a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.