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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 15, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on  
January 13, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says there is no documented assessment to support the 
member was expected to require a hospital stay over two midnights. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department (ED) with leg swelling and 
reported orthopnea, but was found to not be in any distress, with normal and stable vitals on room air. The 
enrollee was diagnosed with congestive heart failure (CHF), treated with diuretics and discharged home from 
the ED without admission. Based on the provided documentation, the enrollee was not expected to require 
hospital services that would have likely crossed two midnights as the enrollee was stable enough for discharge 
at the 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DecisionDx-SCC test (0315U). 
 
You asked the Plan to pre-approve the DecisionDx-SCC test (0315U). You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test (0315U) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the DecisionDx-SCC test (0315U).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 7, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 6, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
April 26, 2023, to May 2, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary for 
rehydration. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented with altered mental status and hypernatremia. Although 
the emergency department physician indicated a medical opinion of a need for a two-midnight admission, the 
admitting physician did not indicate at the time of the inpatient admission that it was reasonably expected that 
the enrollees necessary hospital care (including earlier emergency department and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 26, 2023, to May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
February 23, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the coverage criteria 
are not met.  
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 the supplies. Our reviewer says that the 
CGM supplies are not medically reasonable and necessary. Our physician reviewer found that the provided 
records in this case do not document the beneficiary is insulin treated with three or more daily administrations 
of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. 
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor (CGM) supplies provided on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminectomy. 
 
You asked the Plan to pre-approve a percutaneous laminectomy. You say that the enrollee does not want 
opioids and has tried more conservative treatments. The Plan denied your request. The Plan says this procedure 
is experimental/investigational. 
 
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 percutaneous laminectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a percutaneous laminectomy 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 percutaneous laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous laminectomy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the knee brace (L1852) and sleeve (L2397). 
 
You asked the Plan to pay for the knee brace and sleeve. You say that the items were medically necessary. The 
Plan denied your request. The Plan says that the records provided are invalid. 
 
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 provided documentation that shows the records are invalid. 
Therefore, we decided that the Plan has to pay for the knee brace (L1852) and sleeve (L2397).  
 
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 urine polymerase chain reaction (PCR) panel rendered on 
November 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel rendered on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dayspring Compression Device. 
 
You asked the Plan to pre-approve a Dayspring Compression Device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is 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 a Dayspring Compression Device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this item is considered experimental. 
 
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 Dayspring Compression Device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dayspring Compression Device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with power tilt and recline 
and other components. 
 
You asked the Plan to pre-approve Group 2 power wheelchair with multiple power options. You say that you 
are appealing this denial. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 2 power wheelchair with multiple power 
options may be covered if 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 Group 2 power wheelchair with 
multiple power options. Our reviewer says that the enrollee does not meet criteria for this wheelchair. Our 
physician reviewer found the enrollee has a neurologic disorder with functional deficits. The documentation 
does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the 
bladder or spasticity that would require power tilt or recline. Therefore, the specifically requested power 
wheelchair with multiple power options 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 Group 2 power wheelchair with multiple power options have not been met. 
Because the base power wheelchair is denied, the associated components are also denied. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 power wheelchair with power tilt and recline and 
other components.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of neck, soft tissue with 
contrast. 
 
You asked the Plan to pre-approve a CT scan of neck, soft tissue with contrast. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan of neck, soft tissue with 
contrast. Our reviewer says that the service is medically necessary. Our physician reviewer found the request 
for a CT neck for 6 month surveillance within 2 years of the original surgery is reasonable due to the possibility 
of tumor recurrence in this particular type of tumor. 
 
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 CT scan of neck, soft tissue with contrast have been met. Therefore, we 
decided that the Plan has to pre-approve a computed tomography (CT) scan of neck, soft tissue with contrast.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET)/computed 
tomography (CT) scan (78814). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for surveillance. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET/CT scan. Our reviewer says that 
the medical necessity of the requested PET/CT has not been established in the submitted records. Our physician 
reviewer found the enrollee had sigmoid cancer removed in 2021. The enrollee has had 3 surveillance 
colonoscopies each limited by retained stool. Request for PET/CT is not discussed in the submitted 
records. Conventional imaging has not revealed findings suspicious for tumor. There is no elevation of 
carcinoembryonic antigen (CEA) level to indicate possible recurrence. 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET)/computed tomography (CT) scan (78814).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes R0070 and Q0092 rendered on April 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 
the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that adequate documentation of the denied 
codes has been supplied by the provider. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes R0070 and Q0092 rendered on April 12, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET)/computed tomography 
(CT) scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says that documentation does not indicate any specific cancer diagnosis that is 
suspected. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET/CT scan. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the elevation of the serum alkaline 
phosphatase level may be seen with an infiltrative bone marrow disorder including leukemia, myeloma, and 
lymphoma. The requested scan makes sense to search for a neoplastic source of the non-hepatic alkaline 
phosphatase level. Examination would be the best single test for further evaluation. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET)/computed tomography (CT) scan.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration for the 
denial of Ozempic for the enrollee. 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 Ozempic.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing rendered 
on January 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) testing rendered on January 5, 2023.