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

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve a stress test with cardiac imaging. You say that you need this service. You 
say that you have a heart blockage. The Plan denied your request. The Plan says the requested stress test is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary for patients experiencing new, recurrent, or worsening cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms and new or previously unrecognized 
uninterpretable ECG. 
 
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 stress test with cardiac imaging. Our 
reviewer says that a stress test with cardiac imaging is not medically necessary. Our physician reviewer found 
the provided electrocardiogram (ECG) does not show an uninterpretable pattern. The reviewer found there is 
no evidence provided that would support the need for radionuclide stress testing. Therefore, the reviewer found 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in th 
enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a stress test with cardiac imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on October 5, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that you paid upfront for the inserts prescribed by your 
chiropractor and would like us to consider them for payment. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on October 5, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 22, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service February 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on March 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic life support routine disposable supplies provided on 
February 19, 2021. 
 
You asked the Plan to pay for the basic life support routine disposable supplies. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are not 
separately payable. 
 
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 A0382 is basic life support routine disposable supplies. 
 
We find that CPT code A0382 is not supported in the medical record. Specifically, this code is a noncovered 
charge. Payment for these items are included in the basic life support charge. Based on this information, we 
decided that Medicare rules for coverage of the basic life support routine disposable supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for the basic life support routine disposable 
supplies provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a bathtub wall rail (E0241). 
 
You asked the Plan to pre-approve a shower chair and a bathtub wall rail. You say that you would like to 
request reconsideration for the denial of the requested items. The items are listed as covered items under the 
enrollees plan. The Plan denied your request. The Plan says the requested items are not covered under the 
enrollees plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab rails are not covered 
because they are not primarily medical in nature.  
 
While a shower chair and a bathtub wall rail 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 pre-approve a shower chair 
(E0240) and a bathtub wall rail (E0241).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Uplinza. 
 
You asked the Plan to pre-approve Uplinza. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says that step therapy criteria have not been 
met. 
 
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 rules say that Medicare covers Part B medications when they are reasonable and necessary but 
allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented 
such criteria for certain Part B medications. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage stating that step therapy criteria have 
not been met for the requested drug. The providers appeal letter specifically indicates that the enrollee has a 
history of taking Uplinza and their symptoms have remained stable while on Uplinza. Medical records were not 
included with the case file yet the provider specifically references medical records as being attached. It is 
unclear why these records were not included in the case file. The Plan has not made a reasonable and diligent 
effort to include the documentation necessary to review this case, especially given that it does not appear that 
Uplinza is a new start. Therefore, we decided that the Plan has to pre-approve Uplinza.  
 
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 Foundation One CDx testing services (0037U) provided 
on November 1, 2021. 
 
You asked the Plan to pay for the Foundation One CDx testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this particular genetic 
testing is never covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that the requested genetic testing is subject to the criteria 
for coverage listed 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 pay for the Foundation One CDx testing services. 
Our reviewer says that the ordered testing was not medically reasonable and necessary. Our physician reviewer 
found that the enrollee is a 69-year-old woman with a diagnosis of metastatic recurrent high-grade serous 
carcinoma of the uterus. The case file contains a Test Requisition Form, a Surgical Pathology Report, and the 
results of the testing. The case file does not contain documentation that demonstrates that the enrollee in this 
case has not been previously tested with the same test using NGS for the same cancer genetic content, and has 
decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 Foundation One CDx testing services have not been met. Therefore, we 
decided that the Plan does not have to pay for the Foundation One CDx testing services (0037U) provided on 
November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Euflexxa. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has not tried and failed the preferred drug, Euflexxa. The reviewer found that the 
documentation does not support that Euflexxa would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been 
made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc (J7324).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug screening rendered on January 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, definitive drug screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the drug screening rendered on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand system. 
 
You asked the Plan to pre-approve a combination sit to stand system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Feraheme. Our reviewer says that the 
requirements for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a 
trial of Ferrlecit, Sodium ferric gluconate, Infed, or Venofer before they will approve the requested drug. The 
provided records do not indicate that the enrollee has tried and failed these drugs. The records also do not 
indicate that the enrollee has a contraindication to or would have an adverse effect from these drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power wheelchair, group 3 standard, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds coded as K0861, E2311, E2377, 
E2313, E2361, E1007, E1028, E0955, E1012, and E2603. 
 
You asked the Plan to pre-approve the power wheelchair and components. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says that the request for 
a group 3 multiple power option power wheelchair does not meet medical necessity criteria. All associated 
accessories cannot be approved without an approved base chair and therefore also not covered at this time. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 power wheelchair and components. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical documentation states that enrollee has weakness in all 4 
limbs due to bilateral stroke with inability to independently reposition for seating and lower limbs thus a power 
wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and 
including 300 pounds  (K0861) and components E2311, E2377, E2313, E2361, E1007, E1028, E0955, E1012, 
and E2603 is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair and components have been met. Therefore, we decided that the Plan has to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds coded as K0861, E2311, E2377, E2313, 
E2361, E1007, E1028, E0955, E1012, and E2603.  
 
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 genetic testing services provided on September 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on September 
20, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be more stable, but it is unclear if she is able to wean right 
now. She should only require short-term additional acute care services that can safely be completed at the 
current facility until more stable and appropriate for a lower level of care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous. Completion of treatment at the current 
facility is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig. 
 
You asked the Plan to pre-approve Aimovig. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 Aimovig.  
 
Benefits for Aimovig 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted laparoscopy procedure (43289-22, 43289-62) 
provided on October 2, 2021. 
 
You asked the Plan to pay for the unlisted laparoscopy procedure. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says they have processed the 
codes billed correctly and no payment is due. 
 
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 43289 is unlisted laparoscopy procedure, esophagus. 
 
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 unlisted laparoscopy procedure. Our reviewer says that 
this claim has not been billed appropriately based on Medicare billing regulations. Our reviewer found the 
provider performed services in same anatomical location, therefore billing the same unlisted code for the procedure performed would not be covered. If the physician performs two or more procedures on the same 
anatomic location that require the use of the same unlisted code, the unlisted code should be reported only once 
to identify the services provided. If two or more procedures that require an unlisted code are performed on 
different anatomic locations, the unlisted code may be reported for each different anatomic location. Therefore, 
in this case the documentation does not support payment for the services billed. 
 
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 unlisted laparoscopy procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the unlisted laparoscopy procedure (43289-22, 43289-62) provided on 
October 2, 2021.