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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items 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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the provided records document that the enrollee 
has 5/5 upper extremity grip strength and is modified independent with eating and grooming, thus indicating 
that the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options 
with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding knee walker. 
 
You asked the Plan to pre-approve a folding knee walker. You say that you have an amputated leg and need 
this medical equipment to not lose your other leg. The Plan denied your request. The Plan says the requested 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that knee walkers are not covered. 
 
We looked at the file and Medicare rules. The item at issue is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of a folding knee walker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a folding knee walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions. 
 
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions. The Plan denied your request. The 
Plan says percutaneous lysis of epidural adhesions 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 percutaneous lysis of epidural 
adhesions. Our reviewer says that percutaneous lysis of epidural adhesions is not medically necessary. Our 
physician reviewer found that there is no documentation of any changes in the intra-thecal pump dosage or 
drug mixtures. Also, lysis of epidural adhesions is considered experimental and investigational. Therefore, the 
request is 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 percutaneous lysis of epidural adhesions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Venofer. 
 
You asked the Plan to pre-approve Venofer. You say that it would be in the enrollee's best interests to receive 
this therapy. The Plan denied your request. The Plan says that Venofer is only approved for the treatment of 
severe chronic kidney disease and only when furnished to patients undergoing chronic hemodialysis who are 
receiving supplemental erythropoietin therapy. 
 
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 submit supporting medical records for review. We requested 
this information, but it was not submitted to us. Without this information, we cannot determine whether the 
requested use of Venofer is medically reasonable and necessary for the enrollee. Therefore, the Plan has not 
shown that its decision to deny authorization for this drug is medically correct or justified. Therefore, we 
decided that the Plan has to pre-approve use of Venofer.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 8, 2023.  
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99285 is bundled into payment for code 99239. 
 
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, we have confirmed that code 99285 
is a column II code to column I code 99239 with a modifier indicator of 0. The column II code is therefore not payable. 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 code 99285 billed for date of service May 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on February 3, 2023, billed 
with procedure codes 71045, 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on February 3, 2023, billed 
with procedure codes 71045, 74230, 72040, 70100, 70310, and 74240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 system. 
 
You asked the Plan to pre-approve a Life2000 system. You say that a Life2000 system is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a Life2000 system is 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Life2000 system. Our reviewer says 
that a Life2000 system is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has COPD. The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
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 Life2000 system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Life2000 system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve the drug. You say that Procrit was subscribed to help the enrollee increase 
their hemoglobin. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 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 Procrit.  
 
Benefits for the drug 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 lab services provided on March 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 lab services provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 9, 2022, billed 
with procedure code 99233. 
 
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 claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
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 inappropriately billed with 
POS 21 as documentation shows the enrollee was registered as outpatient observation on the date of service in 
question. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
September 9, 2022, billed with procedure code 99233.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) provided on April 20, 2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this test was reported with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the specimen in question is a tissue 
sample from a cancerous tumor, which would have been collected in a medically necessary hospital encounter. 
This test was performed following the enrollee's discharge from this stay. This means that the appropriate date 
to report in this case would be the date the test was performed/reported: April 20, 2023. Therefore, we decided 
that the Plan has to pay for Breast Cancer Index testing (81518) provided on April 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that this claim should be paid. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 17, 
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 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 lab services provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the injection. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the request 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there was no documentation of at least 50% sustained improvement in pain relief and/or 
improvement in function measured from the enrollee's baseline for at least three months from the previous 
epidural steroid injection. Therefore, the criteria for coverage have not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an ESI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies (T4522, T4535) purchased March 7, 
2023.  
 
You asked the Plan to pay for incontinence supplies. You say that the incontinence supplies are critical in order 
for the enrollee to thrive. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies (T4522, T4535) 
purchased March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service March 27, 
2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the code 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 code G0481 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the provided medical record 
does not contain a physician order identifying the 8 to 14 drug classes to be tested. Based on this information, 
we decided that Medicare rules for coverage of procedure code G0481 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0481 billed for date of service March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87640, 87651, 87798, U0004 and U0005) billed for date of service October 14, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, 87798, U0004 and 
U0005) billed for date of service October 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs 
transportation to critical treatment. The Plan denied your request. The Plan says the requested trips exceed the 
enrollee's transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.