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

 
We decided that the Plan has to pre-approve a freestyle libre 2 continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says that the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 the CGM. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found that the enrollee is taking insulin and meets the 
clinical requirements to be approved. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a freestyle libre 2 continuous glucose monitor (CGM) sensor.  
 
  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 Tempus xF liquid biopsy (81455) provided on January 8, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 8, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service June 24, 2022, to July 
23, 2022. 
 
You asked the Plan to pay for the billed services. You say that proof of timely filing has been submitted. The 
Plan denied your request. The Plan says that the NOA was not submitted timely. 
 
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. 
 
We looked at the file and the rules. The information in the case file shows that an NOA was submitted and 
accepted by the Plan on July 12, 2022. The Plan does not indicate that this NOA was not valid. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the home health care billed for dates of 
service June 24, 2022, to July 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
13, 2022. 
 
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 the documents do not support this level of care. 
 
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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 not supported by the medical records. Our reviewer found that the documentation reflects a 
comprehensive exam, but not a comprehensive history or decision making of high medical complexity. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on May 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Inpatient hospital care provided on March 6, 2022, to April 15, 2022. 
 
You asked the Plan to pay for the Inpatient hospital care provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the services provided are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the Inpatient hospital care provided. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee was a then, 28-year-old male with a history of Schizophrenia, 
hypertension, and Diabetes Mellitus who was originally admitted January 25,2022 after self-inflicted chain saw 
injuries secondary to suicide attempt. He has injuries to neck, scalp, and left hand. He underwent partial 
amputation left hand and was treated by Orthopedics and Plastic surgery. He required wound care and therapy 
services. He also developed a deep vein thrombosis of the right lower extremity treated with Eliquis. He was 
transferred to Psychiatry on February 15, 2022, and required ongoing psychiatric evaluation and treatment. The 
review has determined that the inpatient hospital care provided on March 6, 2022, to April 15, 2022, was 
medically necessary and reasonable. 
 
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 Inpatient hospital care provided have been met. Therefore, we decided that 
the Plan has to pay for Inpatient hospital care provided on March 6, 2022, to April 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 1, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2331, E2377, K0108). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the upper limb strength and function are adequate for the enrollee to be able to control 
the power options using their own switches which are included in the allowance of these power options. 
 
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 services. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has adequate upper body strength to manage the standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Our review found that E2311, E2313, 
E2331, and E2377 are not medically necessary. Additionally, K0108 - the bag hooks - do not serve a primarily 
medical purpose. 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 pre-approve additional power wheelchair 
accessories (E2311, E2313, E2331, E2377, K0108).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Practitioner services provided on September 8, 2022, billed with 
evaluation and management (EM) code 99213. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that payment for this service is included in the 
payment of the primary procedure. 
 
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. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan says that payment for procedure code 99213 is included in the payment of another service. The Plan 
has not provided evidence of the procedure that the EM code is bundled with. As such denial of payment for 
the service provided is not substantiated. Therefore, we decided that the Plan has to pay for Practitioner 
services provided on September 8, 2022, billed with evaluation and management (EM) code 99213.  
 
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 pre-approve implantation of a Hypoglossal Nerve Stimulator 
(64582). 
 You asked the Plan to pre-approve implantation of a Hypoglossal Nerve Stimulator. 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 FDA-approved hypoglossal nerve neurostimulation is 
considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea 
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 implantation of a Hypoglossal Nerve 
Stimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
provided documentation did not clearly show you having failed other more conservative options including 
various masks for a continuous positive airway pressure (CPAP) machine or other appliances with a sleep 
expert or have a follow-up consultation confirming the lower body mass index (BMI) required to meet criteria 
for this specific more invasive procedure. Therefore, this request for the implanted hypoglossal nerve 
stimulator will be considered not medically necessary at this time without the required supportive information. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a Hypoglossal Nerve Stimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantation of a Hypoglossal Nerve Stimulator 
(64582).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cogenex skin graft. 
 
You asked the Plan to pre-approve Cogenex. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 Cogenex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a wound on the right lower leg. Cogenex amniotic membrane and flowable 
amnion are amniotic tissue-based allografts derived from human placenta. Human amniotic membrane grafts 
for lower extremity wounds are considered medically appropriate for the treatment of non-healing diabetic 
lower-extremity skin ulcers. In this case, the wound is a non-pressure chronic non-healing wound and the enrollee is not diabetic. Cogenex in this instance is considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cogenex skin graft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more drug classes 
provided on December 20, 2022. 
 
You asked the Plan to pay for the drug testing as billed. You say that this was necessary as determined by the 
treating physician. The Plan denied your request. The Plan says there was no need to test 22 or more classes. It 
was medically reasonable to test up to 2 drug classes for confirmation. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing may be considered medically 
necessary based on the LCD guidelines listed 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 drug testing as billed. Our reviewer says 
that the testing performed on 22 or more drug classes is not shown to be reasonable and necessary based on 
LCD guidelines.  Our physician reviewer found the enrollee has chronic pain from demyelinating disease and 
polyneuropathy from diabetes. He was taking Tramadol and Tylenol. He had been on opiates in the past. There 
is no documented history of abuse or diversion, and no high-risk behavior or documented failure to follow 
directions. There was no indication for definitive urine toxicology. The testing was 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 drug testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing of 22 or more drug classes provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has restrictive disease on 
pulmonary function testing. Provided records document that the home ventilator is being requested for use in a 
volume assured pressure support (VAPS) mode which is a modality that could be provided by a bilevel positive 
airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve the medication. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mounjaro.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abatacept. 
 You asked the Plan to pre-approve Abatacept. You say that Abatacept is medically necessary. The Plan denied 
your request. The Plan says a trial of Inflectra or Remicade is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Abatacept. Our reviewer says that 
Abatacept is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abatacept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abatacept.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the monitored anesthesia care (MAC) rendered on February 21, 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 that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MAC is 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 pay for these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee has a history of unspecified atrial 
fibrillation, atherosclerotic heart disease, aortic valve replacement, and hypertension. MAC was requested for 
transesophageal electrocardiography (TEE). The records support that MAC was necessary to ensure smooth 
anesthesia and surgery to prevent adverse physiologic complications. The criteria for coverage are met and the 
MAC was reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the monitored anesthesia care (MAC) rendered on February 21, 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.