Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says testing to diagnose obstructive sleep apnea can be safely provided with a home 
sleep apnea test. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study can be covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has confirmed obstructive 
sleep apnea and does not require a repeat sleep study at this time per documentation provided.  
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the enrollee must use network providers to get 
her medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a home ventilator (E0466) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81225, 81231, 81232, 81306, and 81335. 
 You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 12, 2022, billed with codes 81225, 81231, 81232, 81306, and 81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral device (E0260) provided on April 25, 2023. 
 
You asked the Plan to pay for an oral device. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an oral device (E0260) provided on 
April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for the vascular compression unit (VCU) (E0217) provided on 
August 1, 2022. 
 
You asked the Plan  to pay for the VCU. You say that the item was medically necessary. The Plan denied your 
request. The Plan says this item was used for preventative services. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. If code E0215 or 
E0217 is provided it 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 PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have  to 
pay for the vascular compression unit (VCU) (E0217) provided on August 1, 2022.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that due to a recall of the Plan's preferred drug, Avastin, the 
enrollee will need alternative treatment. You are requesting pre-approval of Eylea. The Plan denied your 
request. The Plan says that the enrollee must first try or be unable to use the Plan's preferred medications which 
are a trial of at least 3 doses, resulting in minimal clinical response to, compounded Avastin. 
 
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 failed to address your argument that the requested drug was necessary 
due to a recall of the Plan's preferred drug, Avastin, and therefore, your inability to obtain the requested drug, 
Eylea. Therefore, we decided that the Plan has to pre-approve Eylea.  
 
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 video capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a video capsule endoscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee has a pacemaker. 
 
The Plan must follow Medicare rules. Medicare rules say that wireless capsule endoscopy should not be used in 
patients with a cardiac pacemaker.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a video capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a video capsule endoscopy (91110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 14, 2023, to 
May 13, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue and 
the NOA submitted did not report the first date in 2022 as required. Based on this information, we find that the 
Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from April 14, 2023, to May 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
February 24, 2023, through March 14, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically  The 
Plan denied your request. The Plan says this item was used for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on February 24, 2023, through March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on 
December 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necesary. 
The Plan denied your request. The Plan says the item was used for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a raised toilet seat is not covered. 
 
Medicare does not cover the requested item at this time. Based on this information, we decided that Medicare 
rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-
approve a raised toilet seat (E0244).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and a 
segmental pneumatic appliance for use with a pneumatic compressor, full leg (E0667) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the enrollee must use network providers 
to get his medical care and services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0651) and a segmental pneumatic appliance for use with a pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve a Volara system. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item 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 a Volara system. Our reviewer says that 
the requested item is are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device has not been studied enough to show benefit in the treatment of any chronic lung 
disease. There is inadequate evidence that this device is as, or more, effective than other devices in achieving 
airways clearance.  
 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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system.
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 services are medically necessary. The Plan 
denied your request. The Plan says admission to IRF is not reasonable and 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 the enrollee does not require treatment by multiple therapies. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5110 and D5120). 
 
You asked the Plan to pre-approve the dental services (D5110 and D5120). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 18, 2023. Therefore, 
we decided that the Plan does not have to pre-approve the dental services (D5110 and D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU) (E0217). 
 
You asked the Plan to pay for the VCU. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this item was used for preventative services. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  If code E0215 or 
E0217 is provided it 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 PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the vascular compression unit (VCU) (E0217).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity for a repeat sleep study is not met. 
 
The Plan follows Medicare rules. Medicare rules say that a sleep study can be covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has an adequate sleep study 
and repeat is not indicated or supported by documentation provided. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that despite treatment with PAP therapy 
the enrollee persists to retain critical levels of carbon dioxide. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a 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. 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
was treated with a BiPAP successfully and can also be treated with BiPAP with AVAPS capability, which has 
been approved by the Plan. The documentation does not contain sufficient detailed information to justify the 
treatment selected. Therefore, the elements of the coverage criteria are not satisfied, and the requested service 
cannot be recommended. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
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 the home ventilator. You say that the enrollee is re-admission, for the past 
year and has been admitted 6 times and was just discharged a week ago. You also say that BiPAP is not 
sufficient and can be deadly to the enrollee if they do not receive home ventilator.  The Plan denied your 
request. The Plan says  the home ventilator is not reasonable or 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 chronic obstructive pulmonary disease (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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has COPD and 
responded appropriately to BiPAP therapy and did not show failure of BiPAP. The enrollee does not have the 
document support for a home ventilator. Hence, no home ventilator can be approved per the documentation 
provided. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.