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

 
We decided that the Plan has to pay for the supplies received from February 14, 2023, to March 13, 2023. 
 
You asked the Plan to pay for the supplies. 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. 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. Medicare rules also say that durable medical equipment (DME) supplies must be provided with a 
proof of delivery. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The required documentation pertaining to the proof of delivery of these supplies 
has been provided. The plan has not substantiated their denial in this case. There is a Fedex proof of delivery 
with a valid tracking number that matches the shipping date and sending and receiving locations from the sales 
order. This is sufficient to show proof of delivery. Therefore, we decided that the Plan has to pay for the 
supplies received from February 14, 2023, to March 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that you have tried and failed Metformin, Invokana, 
Victoza, Toujeo, Levemir, Ozempic, and Trulicity. 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 Mounjaro.  
 
Benefits for Mounjaro 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot adequately recover in a lower 
level of care. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
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 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 medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the push wheelchair repairs coded as E0986, K010 and K0739. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the enrollee uses the wheelchair in the 
home and will need all of the accessories covered and fixed for mobility. The Plan denied your request. The 
Plan says that the cost of repairs previous and current is much higher than initial purchase price and it is 
nearing the 5-year mark since the purchase was done on October 12, 2018. 
 
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 of the previous repairs that was 
completed and the cost of those previous repairs. The Plan has only provided the current work order of the 
repairs being requested. The Plan has not provided any information to substantiate their reason to deny the 
wheelchair repairs. Therefore, we decided that the Plan has to pre-approve the push wheelchair repairs coded as 
E0986, K010 and K0739.  
 
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 a home ventilator. You say that this device is medically necessary and other 
options will not meet the patient's needs. The Plan denied your request. The Plan says the patient's needs can be 
met with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support 
(AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has chronic 
respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee was 
treated with a BiPAP device.  The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability and failure of such a device has not been documented.  The plan has indicated 
coverage for such a device is available upon request. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that a MyoPro orthosis is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a MyoPro orthosis 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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes 
for the enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a broken hip, and the hip 
replacement surgery needs the therapy services. You also say that without the intense therapy the enrollee will 
not be able to recover. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services requested do not meet the requirements for approval. 
 
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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is being discharged but 
medically cannot go home. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The requested 
service cannot be recommended as the elements of the coverage rules are not satisfied. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional months of continued noninvasive 
interface ventilator (NIV) use (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the clinical information provided supports that 
BiPAP is not enough, and the enrollee must have a NIV to prevent future hospitalizations. The Plan denied 
your request. The Plan says continued use of a NIV is not medically reasonable and 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 the ventilator. Our physician reviewer 
found Medicare does not cover a home ventilator when used at settings that can be provided with bilevel 
positive airway pressure (BiPAP). The Plan has approved the ventilator for 3 months, which allows time for 
transition to BiPAP. The denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) additional months of continued noninvasive interface ventilator (NIV) use 
(E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0481 rendered on February 1, 
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 denied codes remain not supported. 
 
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: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
Healthcare Common Procedure Coding System (HCPCS) G0481: 
 
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 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 no medical records or laboratory 
reports were identified for review. Therefore, there is no evidence that the ordered test was medically necessary 
or performed. 
 
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 procedure codes 80307 and G0481 rendered on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 10, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
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. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99215 and 20611 billed for date of service 
September 19, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting.  The CPT Code Manual definition of code 99215 is office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent 
on the date of the encounter. 
 
We find that CPT codes 99215 and 20611 are not supported in the medical record. The records show that the 
enrollee was seen for joint pain and stiffness. The records do not show that a high level of decision making was 
provided. The records do not indicate the amount of time spent with the enrollee. The records do not include 
documentation of ultrasound guidance with permanent recording and reporting. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99215 and 20611 billed for date of service September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Confirm MDx (81551) provided on February 17, 2023.  
 
You asked the Plan to pay for Confirm MDx. You say that this testing is standard of care for the management 
of men at risk for undetected prostate cancer. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested test as he was not under consideration for a repeat biopsy and there were no 
persistent risk factors such as a repeat PSA or DRE exam that were abnormal. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the 
Medicare rules section of this letter 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 Confirm MDx. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Confirm MDx is performed to stratify those 
who are considering a second biopsy. The medical records show that the enrollee had a PSA of 3.17 on 
September 20, 2022, and an increase to 4.09 on January 27, 2023. A prior DRE revealed a smooth enlarged 
prostate on October 9, 2020. The records confirm that the first biopsy was performed on February 17, 2023, 
and the Confirm MDx was ordered on the same day. The result of the biopsy was benign. The results of the 
Confirm MDx test were negative. The provider did not indicate they were considering a second repeat biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Confirm MDx have not been met. Therefore, we decided that the Plan does not 
have to pay for Confirm MDx (81551) provided on February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulator (TENS) 
electrodes (A4556) provided on November 4, 2022. 
 
You asked the Plan to pay for the TENS electrodes. You say that the item should be covered. The Plan denied 
your request. The Plan says a TENS device is not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain 
(CLBP) will be denied as not reasonable and necessary. Reimbursement for supplies is contingent upon use 
with a covered TENS unit. Claims for TENS supplies provided when there is no covered TENS unit will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS electrodes have not been met. Therefore, we decided that the Plan does not have to pay 
for the Transcutaneous Electrical Nerve Stimulator (TENS) electrodes (A4556) provided on November 4, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure oral nutrition.  
 
You asked the Plan to pre-approve Ensure. You say that you do not have money for food and are losing weight.  
The Plan denied your request. The Plan says enteral nutrition products are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure oral nutrition.