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

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that this is 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 foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated pressure and compression garment. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have chronic 
venous insufficiency and lymphedema as well as peripheral vascular disease affecting the lower extremities. 
The documentation indicates that the patient has tried conservative measures, including compression stockings 
and lymphedema treatment. A trial of a basic pneumatic compression to manage his condition has not been tried and failed. The requested non-pneumatic compression controller is not considered superior to standard 
lymphatic devices. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-pneumatic compression controller with sequential calibrated pressure and 
compression garment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a serious and life altering 
constellation of acute medical problems that have left them at a functional status below their baseline. You also 
say the enrollee requires active physician oversight and the IRF setting is the most appropriate to reach the 
desired outcomes. The Plan denied your request. The Plan says the enrollee does not meet all the requirements 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DPYD genetic testing. 
 
You asked the Plan to pre-approve DPYD gene test. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that pharmacogenomics testing is only covered when the 
clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene interactions 
that require a PGx test to be ordered to define the safe use of that drug in that patient. 
 
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 DPYD gene test. Our reviewer says that 
you do not meet criteria for this test. Our physician reviewer found you have diagnoses of mycobacterium 
avium complex pulmonary disease and advanced bronchiectasis. You have received multiple oral and 
intravenous antibiotic regimens. Your pulmonologist noted that you were on triple-drug daily mycobacterial therapy and suspected sterilization of cavities and sputum conversion will not occur. The record does not 
clearly show that the use or intent to prescribe a drug that has known drug-gene interactions requires this 
testing to define the safe use of this drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DPYD gene test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve DPYD genetic testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100) and diagnostic radiology procedures of the head and neck (CPT 70310) provided on 
May 25, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100) and diagnostic 
radiology procedures of the head and neck (CPT 70310). You say that the services were medically necessary.  
The Plan denied your request. The Plan says the documentation supports the studies were performed at a 
nursing home (via mobile van/portable x-ray) which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100) and diagnostic radiology procedures 
of the head and neck (CPT 70310) have not been met. Therefore, we decided that the Plan does not have to pay 
for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100) and diagnostic radiology procedures of the 
head and neck (CPT 70310) provided on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home. They 
are a fall risk and require IRF services. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 16, 2023, billed 
with code 99214. 
 
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 the diagnosis code is inappropriately coded. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. This claim was billed with diagnosis codes 
M54.59 and M51.26 which is a code pair that is subject to an Excludes1 note and cannot be reported together. Therefore, we decided that the Plan does not have to pay for Practitioner services provided on January 16, 
2023, billed with code 99214.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the prostate cancer screening provided on August 3, 2022. 
 
You asked the Plan to pay for the prostate cancer screening. You say that this service was medically necessary 
and appropriate. The Plan denied your request. The Plan says that you are entitled to one prostate cancer 
screening every 12 months. However, you previously had this service in February 2022, and it was covered at 
that time. The second test within a 12-month period, provided on August 3, 2022, is not covered. 
 
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 provided no documentation to show that you 
previously had this screening within 12 months of the date in question, and that this previous service was paid. 
The Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the 
prostate cancer screening provided on August 3, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve a catheter placement in coronary artery(s) for coronary angiography. The 
Plan denied your request. The Plan says this request cannot be approved. 
 
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 catheter placement in coronary 
artery(s) for coronary angiography. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided documentation 
does not clearly show the enrollee with new, recurrent, or worsening symptoms or findings suggestive of 
cardiac ischemia to justify this test. There was no myocardial perfusion or stress test showing evidence of 
ischemia. Our reviewer found that therefore, the catheter placement in coronary artery(s) for coronary 
angiography (93458) will be considered not medically necessary as the records did not clearly support the use 
of this test 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 a catheter placement in coronary artery(s) for coronary angiography have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a catheter placement in coronary 
artery(s) for coronary angiography (93458).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA of the coronary arteries. 
 
You asked the Plan to pre-approve CTA of the coronary arteries. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested imaging 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 CTA of the coronary arteries. Our 
reviewer says that the requested imaging is not medically necessary. Our physician reviewer found the enrollee 
has no cardiac symptoms. Clinical guidelines for the use of coronary CTA have not been met based on review 
of the submitted clinical documentation. As a result, at this time coronary CTA would not be considered 
medically reasonable and necessary in the enrollee's clinical management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA of the coronary arteries have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CTA of the coronary arteries.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 16, 2022, 
to October 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be reprocessed because 
upon reviewing the claim there were no errors found. The Plan denied your request. The Plan says the NOA 
was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 17, 2022. The NOA was not received by the Plan until November 
21, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from September 16, 2022, to October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided February 
1, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the laboratory services rendered were 
medically necessary and you have submitted medical documentation to support. The Plan denied your request. 
The Plan says under Medicare guidelines, this request is not medically necessary because the records do not 
show that the enrollee has advanced, metastatic, recurrent, and refractory cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Under Medicare guidelines, this request is not medically necessary 
because the records do not show that the enrollee has advanced, metastatic, recurrent, and refractory cancer. 
The records show that the enrollee stage pT1b squamous cell carcinoma. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the FoundationOne CDx testing (0037U) provided February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a backup battery (E1356) and a credit card service fee 
(A9270). 
 
You asked the Plan to pay for a backup battery and a credit card service fee. You say that this should be 
covered. The Plan denied your request. The Plan says a backup battery is a convenience item and a credit card 
service is fee is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that your oxygen concentrator came with a battery. A backup battery is a duplicate item that 
does not serve a medical purpose, but one of convenience. Therefore, we decided that the Plan does not have to 
pay for a backup battery (E1356) and a credit card service fee (A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without an IRF admission the enrollee may regress 
and get worse. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with high gold content crown, tooth 21 (D2750). 
 
You asked the Plan to pre-approve a crown . You say that this is medically necessary. The Plan denied your 
request. The Plan says that your tooth has to have a lot of tooth missing from a cavity or have a lot of damage 
from being broken and it can no longer be fixed with a filling. The x-rays your dentist sent show a crown is not 
needed to fix your tooth. 
 
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 did not provide sufficient x-rays to determine if the crown was 
medically necessary or not. Therefore, we decided that the Plan has to pre-approve white glass with high gold 
content crown, tooth 21 (D2750).  
 
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 home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has asthma, heart failure with preserved ejection fraction (HFpEF), and severe obesity with a body mass index of greater than 52. There 
is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or 
neuromuscular disease. The home ventilator is therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.