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

 
We decided that the Plan does not have to pre-approve excessive skin and subcutaneous tissue (includes 
lipectomy); abdomen infraumbilical panniculectomy. 
 
You asked the Plan to pre-approve excessive skin and subcutaneous tissue. You say that the enrollee would 
benefit from this because she gets reoccurring yeast infections. The Plan denied your request. The Plan says the 
requested surgery is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve excessive skin and subcutaneous tissue. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support that the enrollee has chronic 
intertrigo that consistently remains refractory despite appropriate medical therapy over a period of three 
months, or difficulty walking or functional impairment in activities of daily living.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excessive skin and subcutaneous tissue have not been met. Therefore, we 
decided that the Plan does not have to pre-approve excessive skin and subcutaneous tissue (includes 
lipectomy); abdomen infraumbilical panniculectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 7, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on March 7, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483). 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary to monitor this enrollee on chronic opioid therapy. The Plan denied your request. The Plan 
says that ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in clinical 
management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that a 
definitive urinary toxicology was sent. The results show inconsistent results with THC detected as well as the 
absence of clonazepam. The definitive testing was indicated due to the inconsistently along with the presence 
of THC which was not prescribed. The testing was medically reasonable and 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 definitive UDT for 22 or more drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483).  
 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 pneumatic compressor (E0651), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, full arm (E0668) 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliances. You say that 
you have an upcoming surgery on your right shoulder and your doctor is concerned about you clotting. You 
also say that you need these devices before your surgery to help with the healing process. The Plan denied your 
request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD is medically necessary for the treatment of 
lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. Medicare rules also 
say that if the base PCD is not covered, related accessories are not eligible for reimbursement and 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 a pneumatic compressor and segmental 
pneumatic appliances. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer 
found the documentation does not support that you have failed at least 4 weeks of conservative care with a 
basic lymphedema pump.  Additionally, the documentation does not support that you have physical findings 
consisting of truncal, abdominal or chest edema. 
 
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 pneumatic compressor and segmental pneumatic appliances have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0651), 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic 
appliance for use with pneumatic compressor, full arm (E0668)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the electronics are medically necessary 
to provide the enrollee with the most independence with pressure relief possible. The Plan denied your request. 
The Plan says upgraded electronics cannot be covered per Medicare rules. They are necessary when there is a 
medical need to control power options though the joystick. 
 
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 an expandable controller is an electronic system that is capable of accommodating 
one or more additional features and can operate 3 or more powered seating options. The requested electrical 
accessories are not medically necessary as the enrollee does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic wheelchair. There is not a 
medical need for the upgraded electronics. 
 
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 an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat ESI. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee's pain relief from the initial ESI did not last for three 
months. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that the 
requested repeat ESI is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee has had 50% pain relief for three months. Therefore, the reviewer found that the request for a repeat ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a periodic comprehensive preventive medicine exam (CPT 99397) 
provided on April 14, 2023. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine exam. You say that this 
appointment was for your gynecologist exam, which was two years between exams, and the other visit in 
March was with your PCP. The Plan denied your request. The Plan says that your Evidence of Coverage on 
page 55 for annual wellness visit; If you've had Part B for longer than 12 months, you can get an annual 
wellness visit to develop or update a personalized prevention plan based on your current 
health and risk factors. This is covered once every 12 months.  
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule stating the 
periodic comprehensive preventive medicine exam (CPT 99397) benefit has been exhausted. The Plan based 
their decision on an Annual Wellness Visit benefit, which does not apply to this service. Therefore, we decided 
that the Plan has to pay for a periodic comprehensive preventive medicine exam (CPT 99397) provided on 
April 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99214 for date of service 
May 8, 2023. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. 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 11042 
provided on the same date of service. 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 the office visit billed 
with code 99214 for date of service May 8, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing provided on October 4, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the services are considered experimental/investigational. 
 
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. The Plan has not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request. The Plan did not specify whether the ordering 
provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior 
notice from the Plan that this testing would not be covered. Without this information, we cannot determine 
whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to 
deny payment for this testing is correct or justified. Therefore, we decided that the Plan has to pay for 
diagnostic testing provided on October 4, 2022. Therefore, we decided that the Plan has to pay for diagnostic 
testing provided on October 4, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 20936. You say that the medical record supports payment of this 
service. The Plan denied your request. The Plan says procedure code 20936 is considered bundled and not 
separately payable.  
 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 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service September 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trans-Cranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TMS of the brain for severe MDD, single or recurrent 
episode, is considered medically reasonable and necessary for up to six weeks when certain 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 TMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found documentation presented is not specified what medications this enrollee had been taking during the present episode of depression. This enrollee has the 
correct diagnosis. She has not undergone the medication regimen as described in the coverage criteria. 
Therefore, the enrollee does not meet the criteria for Transcranial Magnetic Stimulation (TMS). It is therefore 
not considered reasonable or 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 TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trans-Cranial Magnetic Stimulation (TMS).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended sleep study (95811). 
 
You asked the Plan to pre-approve an attended sleep study. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for an attended study. A home sleep 
apnea test would be approved if requested. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an attended sleep study. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found this enrollee has excessive 
daytime sleepiness with an Epworth sleepiness score of 12. The enrollee does not have any conditions that 
would prevent a home sleep study, such as severe heart or lung disease. The clinical notes do not indicate a 
suspicion of sleep disorders other than obstructive sleep apnea. A home sleep study followed by initiation of 
auto titrating CPAP would be a reasonable approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attended sleep study (95811).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the indication for coverage is not met due to multi-level disease to L3-L5 
involving facet joints, lateral recesses, and discs. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records in this case document evidence of thickened ligamentum 
flavum, narrowed lateral recess, and/or central canal or foraminal narrowing at three levels: L3-L4, L4-L5 and 
at L5-S1. The Vertiflex device may be implanted at one or two adjacent lumbar levels in patients in whom 
operative treatment is indicated at no more than two levels, from L1 to L5. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronic acid injections to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve hyaluronic acid injections. You say that you had relief of your knee pain 
from these injections before. The Plan denied your request. The Plan says this provider is out-of-network with 
the Plan and you can be treated within the Plan network. 
 
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 
hyaluronic acid injections to be provided by an out-of-network (OON) provider.
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 services are medically necessary for you to get 
the services needed to return to being independent. 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 do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in 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 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.