Persius/hicric huggingface dataset:
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 inpatient rehabilitation is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for inpatient rehabilitation 
facility stay.  
 
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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation needs 
do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement; however, the documentation doesnt support that he would meet criteria for admission 
to an acute inpatient rehabilitation facility.  There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status.  The enrollee can receive 
further services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Woundfix.  
 
You asked the Plan to pre-approve Woundfix. You say that Woundfix is medically necessary due to bed sores.  
The Plan denied your request. The Plan says the requested Woundfix is experimental and 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 Woundfix. Our reviewer says that the 
requested Woundfix is not considered medically reasonable and necessary. Our physician reviewer found that 
you have decubitus pressure ulcers having failed general wound care treatment. Only a few grafting products 
are approved for this purpose and Woundfix is considered investigational as it does not have sufficient high-
quality evidence to support its use in this clinical situation. Therefore, this request for Woundfix will not be 
considered medically necessary at this time based on currently available literature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Woundfix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Woundfix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 16, 2023, billed with 
codes 87481, 87500, 87640, 87652, 87798, 87799 and 87900. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 16, 2023, billed with codes 87481, 87500, 87640, 87652, 87798, 87799 and 87900.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (87086) provided on April 4, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed diagnosis code 
is not appropriate for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are covered for 
urine culture testing. 
 
We looked at the file and Medicare rules. Per NCD 190.12., the billed diagnosis code, N81.11, is not covered 
for code 87086. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing (87086) provided on April 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 17, 2023, billed with 
procedure codes 96365-59 and 96366-59. 
 
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 codes 96365 and 96366 are inappropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 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. The billed procedure is not payable as it is a 
non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on May 17, 2023, billed with procedure codes 96365-59 and 96366-59.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Nalu Neurostimulation System. 
 
You asked the Plan to pre-approve the Nalu Neurostimulation System. You say that the Nalu Neurostimulation 
System is medically necessary. The Plan denied your request. The Plan says this modality for chronic pain 
management is still being studied to see if this treatment is as good or better than standard treatment for chronic 
pain. Thus far, there is insufficient medical literature to support the use of the Nalu system for chronic back 
pain.  
 
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 Nalu Neurostimulation System. Our 
reviewer says that the requested Nalu Neurostimulation System is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Nalu Neurostimulation System is considered experimental/investigational therapy. Therefore, the request is deemed 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 Nalu Neurostimulation System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Nalu Neurostimulation System.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve TissueCypher testing. 
 
You asked the Plan to pre-approve the TissueCypher testing. You say that this service is medically necessary. 
The Plan denied your request. The Plan says that this test is experimental and non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that tested biomarkers must have proven clinical 
validity/utility. 
 
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 TissueCypher testing. Our reviewer 
says that the requested test is medically necessary. Our physician reviewer found a tissue systems pathology 
test better predicts prevalent high grade dysplasia in Barrett's esophagus patients than pathologic variables. 
Studies that molecular and cellular changes associated with malignant transformation in Barrett's esophagus 
may be detectable as a field effect using the requested test. 
 
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 TissueCypher testing have been met. Therefore, we decided that the Plan 
has to pre-approve TissueCypher testing.  
 
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 heavy duty walker with a seat (E0149, E0156). 
 
You asked the Plan to pre-approve the heavy duty walker with a seat. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. The records do not show that the beneficiary weighs more than 300 
pounds. Based on this information, we decided that Medicare rules for coverage of the heavy duty walker with 
a seat have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker 
with a seat (E0149, E0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 senor   
You asked the Plan to pre-approve a Freestyle Libre 2 senor . You say that you need these sensors for the 
alarms so you can prevent your sugars going into the low 20's. This is dangerous and life threatening or you. 
The Plan denied your request. The Plan says the enrollee is not on insulin and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 senor  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 senor
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you would like this item to be covered. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a bathtub grab bar.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computerized Dynamic Posturography. 
 
You asked the Plan to pre-approve Computerized Dynamic Posturography. You say that you do not have the 
physical ability to drive and do normal daily functions because of dizziness. You say that you had magnetic 
resonance imaging (MRI) done, which does not show any results as to why you are dizzy and your doctor 
thinks the Computerized Dynamic Posturography test is necessary to find out the main function of the problem.  
The Plan denied your request. The Plan says the requested Computerized Dynamic Posturography 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 Computerized Dynamic Posturography. 
Our reviewer says that the requested Computerized Dynamic Posturography is not considered medically reasonable and necessary. Our physician reviewer found that the provided medical records and review of the 
current peer-reviewed medical literature do not document that use of Computerized Dynamic Posturography 
has been shown in controlled studies in a Medicare-approved journal to result in long term health benefits in 
patients with dizziness and giddiness.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Computerized Dynamic Posturography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Computerized Dynamic Posturography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for and pay for a podiatry office visit and foot 
orthosis provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for and pay for office visit and foot orthosis. You say that you are 
appealing this denial. The Plan denied your request. The Plan says this cost sharing was charged correctly. The 
Plan also says that the denial of payment for the foot orthosis is correct. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for each podiatry office visit. 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. 
 
You have been asked to pay $40 copayment for office visit. This item/service falls within the Podiatry Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, 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 waive the copayment for and pay for a 
podiatry office visit and foot orthosis provided on January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service February 10, 
2023. 
 You asked the Plan to pay for procedure code 87502. The Plan denied your request. The Plan says payment for 
code 87502 is bundled into payment for code 87633. 
 
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 87502 
is a column II code to column I code 87633. 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 87502 billed for date of 
service February 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A0425 billed for date of service February 4, 2023.  
 
You asked the Plan to pay for code A0425. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim. 
 
In this case, the MUE for CPT code A0425 is 250 The MAI value for this code is 1. You billed 321 units of 
this code on one claim line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A0425 billed for date of service February 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by codes 74230, 74240, 
72040, 70100, 70310, and 71045 performed on February 22, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services performed on 
February 22, 2023, should be paid as billed. The Plan denied your request. The Plan says the radiology services 
described by codes 74230 and 74240 are not covered benefits because they are listed in the Exclusions from 
Coverage as Portable X-Ray Services section of the Medicare Benefit Policy Manual. Radiology services 
described by codes 72040, 70100, 70310, and 71045 were billed with an inappropriate place of service.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that radiology services 
performed in the mobile setting are not eligible for reimbursement if they are listed in the Exclusions from 
Coverage as Portable X-Ray Services section of the Medicare Benefit Policy Manual. Medicare rules also state 
that claims must be billed with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, 70310, and 71045 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services described by codes 74230, 74240, 72040, 70100, 
70310, and 71045 performed on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a hospital bed. You say that the medical records provided support the 
necessity of the requested total electric hospital bed. The Plan denied your request. The Plan says a total 
electric hospital bed is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010), a second 
stage surgical access to an implant body (D6011), a custom fabricated abutment (D6057) and an abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve a surgical placement of implant body (D6010), a second stage surgical 
access to an implant body (D6011), a custom fabricated abutment (D6057) and an abutment supported 
porcelain/ceramic crown (D6058). You say that the dental work needed has not yet done. You also say you are 
eating on one side of your mouth with some real discomfort. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of implant body (D6010), a second stage surgical access to an implant body (D6011), a 
custom fabricated abutment (D6057) and an abutment supported porcelain/ceramic crown (D6058).  
 
Your complaint about the potentially poor treatment from the previous provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on February 9, 2023. 
 You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says there is insufficient information on the physician 
order to verify the test(s) requested in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the laboratory report requests a Urine MCT (All-in-One) test but does not clarify what this 
panel should include. The records support that definitive drug testing was performed, but we cannot verify that 
the services provided were specifically medically necessary and requested by the enrollees treating physician. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 9, 
2023.