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

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve the SPRINT peripheral nerve stimulator. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the Sprint PNS system does not meet the 
Medicare criteria as it is not an implanted peripheral neurostimulator with a trial of implantation showing 
effective pain control. 
 
The Plan follows 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 SPRINT peripheral nerve 
stimulator. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
this would be considered an experimental/ investigational procedure. Therefore, the request is deemed not 
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 SPRINT peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (64555).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0144U) performed on 
June 14, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the quality of evidence for this testing is very low. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was referred for EsoGuard Next Generation Sequencing testing. This testing is not 
standard of care and was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 0144U) performed on June 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on December 
2, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transport would be paid separately as the 
enrollee was discharged from the first facility prior to transfer. The Plan denied your request. The Plan says the 
payment for this transportation would be included in the payment to the facility where the enrollee was 
admitted throughout the date in question. 
 The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility from November 29, 2022, to December 13, 2022. There is no evidence that the 
enrollee was discharged from one facility prior to transport. This means that the services at issue are considered 
patient transportation and paid to the facility. Therefore, we decided that the Plan does not have to pay for 
ambulance services (A0428, A0425) provided on December 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve drug testing (G0482). 
 
You asked the Plan to pre-approve the drug testing. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing may be reasonable and 
necessary based on patient specific indications, including historical use, medication response, and clinical 
assessment, when accurate results are necessary to make clinical decisions. The clinicians rationale for the 
definitive drug testing and the tests ordered must be documented in the patients medical record. 
 
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 drug testing. Our reviewer says that 
this service is medically necessary. Our physician reviewer found the records provided show that the requested 
definitive drug tests are 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 the drug testing have been met. Therefore, we decided that the Plan has to pre-
approve drug testing (G0482).  
 
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 procedure codes 64447, 64450, and 76942 billed for date of 
service January 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
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 have confirmed that codes 64447 and 64450 are a column II code to column I code 01402. Codes 64447 
and 64450 were billed with the -59 modifier. The medical records do not show that the services billed with the 
-59 modifier were distinct procedural services. Based on the claim submitted, Medicare billing criteria have not 
been met. 
 
The CPT Code Manual definition of code 76942 is ultrasonic guidance for needle placement (e.g., biopsy, 
aspiration, injection, localization device), imaging supervision and interpretation. We find that code 76942 is 
not supported. The records provided do not include a written report for the service. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 64447, 64450, and 76942 billed for date of service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that your knees are hurting and are in bad shape. 
The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you have bilateral primary osteoarthritis of the knee and you have problems walking. The 
documentation does not support that you have a mobility deficit that impairs your participation in MRADLs. 
The notes do not show that you cannot use a cane or walker to help you complete your activities of daily living. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for 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 measurements at therapy are for below the knee 
without any measurements at therapy of the thigh, of the chest, trunk or abdomen. This device is only covered 
when enrollees have lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits 
of a standard compression sleeve. You do not meet criteria for the requested device. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliances (E0667 and 
E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe lift, foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested shoe lift, foot orthotics are medically necessary. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe lift, foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter supplies to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the enrollee needs a provider who can deliver 
emergency supplies. The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
catheter supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 5-inch high definition (HD) portable magnifier with 
handle. 
 
You asked the Plan to pre-approve a 5-inch HD portable magnifier with handle. You say that the enrollee 
requires this item due to retinal detachment and retinal neovascularization.  This item will improve his quality 
of life. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that low vision aids of all types of are excluded from 
coverage.  Although the requested item may be helpful for the enrollee, neither Medicare nor the Plan covers 
this item. Therefore, we decided that the Plan does not have to pre-approve a 5-inch high definition (HD) 
portable magnifier with handle.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9604 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 P9604 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. The records provided do not sufficiently 
document services from a trained technician required for travel allowance eligibility. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code P9604 billed for date of service September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical (bone growth 
stimulator) identified with code E0747. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that osteogenesis stimulators are covered when a 
failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last 
surgery. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee received surgery on May 
31, 2023. This means a minimum of nine months has not elapsed since the enrollees last surgery. Based on 
this information, we decided that Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical (bone 
growth stimulator) identified with code E0747.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads 
(93005} provided on January 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic service. You say that please review and reprocess for payment. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 
12 leads (93005} provided on January 19, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that the payment should be allowed. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that no appointment has been made yet for this 
procedure. The Plan denied your request. The Plan says facet joint injections are not medically necessary.   
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 injections. Our reviewer says that 
face joint injections are not medically necessary. Our physician reviewer found that the pain is primarily in the 
thoracic spine and there is non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the enrollee's pain. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
doctor for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied your request. The 
Plan says the MyoPro Motion G (L8702) this is considered experimental and investigational due to insufficient 
evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 9, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The billed test in this case is not covered under the DEX Diagnostics 
Exchange, and therefore is not payable. Based on this information, we decided that Medicare rules for coverage 
of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel Mini injection. 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided support the 
necessity of the requested service. 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 Enbrel Mini injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 16, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
provided on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the requested CGM is 
medically necessary. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization form from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. Based 
on this information, we decided that Medicare rules for coverage of the CGM and related supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) and related supplies.