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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records document that the enrollee has 3+/5 left upper extremity strength with 
"functional" left hand grasp; and is independent with feeding and grooming, thus indicating the enrollee has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.  
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on November 09, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you think that the copayment for 
these services is too high. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a $5 
copayment for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT). 
 
You have been asked to pay a $5 copayment for lab services. This item/service falls within the other Medicare-
covered laboratory tests that are not fecal immunochemical tests (FIT) 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. Therefore, we decided that the Plan 
does not have to waive the copayment for lab services provided on November 09, 2022.
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 you will benefit from therapy at an IRF for 
improving your strength. The Plan denied your request. The Plan says the services are not medically necessary 
under Medicare guidelines. 
 
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 you do 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for AVISE connective tissue disease (CTD) testing provided on April 26, 
2022. 
 
You asked the Plan to pay for CTD testing. You say that this testing provides results which cannot be measured 
using any other commercially available blood test. The Plan denied your request. The Plan says that this testing 
is not covered. 
 
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 say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The records do not include prior notice from the Plan that this testing would not be 
covered. Without this information, we cannot determine whether the lab order made constituted plan-directed 
care. This testing was not ordered for exclusively screening purposes. Therefore, the Plan has not shown that its 
decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we 
decided that the Plan has to pay for AVISE connective tissue disease (CTD) testing provided on April 26, 
2022.  
 
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: Favorable

 
We decided that the Plan has to pay for Guardant Reveal testing (81479) provided on November 2, 2021. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this test was medically necessary and was 
recommended in this case. The Plan denied your request. The Plan says that this test does not meet the criteria 
for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for Guardant Reveal testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was receiving adjuvant chemotherapy for colon cancer, and this test was requested 
to detect residual disease. In patients treated with chemotherapy, the presence of circulating tumor DNA 
(ctDNA) after completion of chemotherapy was also associated with an inferior recurrence-free survival. 
CtDNA detection after stage II colon cancer resection provides direct evidence of residual disease and 
identifies patients at very high risk of recurrence. Therefore, this test was 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 Guardant Reveal testing have been met. Therefore, we decided that the Plan has 
to pay for Guardant Reveal testing (81479) provided on November 2, 2021.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2068) provided on 
November 14, 2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you believe the Plan did not have 
all the necessary information to process this claim correctly. The Plan denied your request. The Plan says 
individual providers cannot bill for OTP services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. The rules also say that only an entity enrolled with 
Medicare as an OTP can bill these codes. 
 
We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. Based on this information, we decided that Medicare 
rules for coverage of the medication assisted treatment have not been met. Therefore, we decided that the Plan 
does not have to pay for the medication assisted treatment (G2068) provided on November 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with denial code G 
rendered from February 1, 2022, to April 11, 2022. 
 
You asked the Plan to pay for the services. You say that you are appealing the recoupment of the partially 
adjustment claim payment. The Plan denied your request. The Plan says several items initially denied due to 
not having an itemized bill have now been identified as routine items and services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 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 the items reported as separate 
charges would be considered "room and board" charges. They cannot be reported separately. 
 
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 inpatient hospital services denied with denial code G rendered from February 1, 2022, to April 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of bisphosphonates is required before alternatives can be considered. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs, or 
any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found 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, based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes/ There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulation supplies billed for date of service August 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that A4595 is an accepted procedure code. The Plan 
denied your request. The Plan says that the proof of delivery did not include an order number or details to 
corroborate the delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and the rules. The Plan denied services as a valid proof of delivery was not submitted. 
The documentation shows a packing slip for the date of service at issue that includes a tracking number and 
itemized list of the items included. The tracking number on the delivery ticket supports the tracking number on 
the packing slip. Based on this information, we decided that the Medicare rules for coverage have been met.  
Therefore, we decided that the Plan has to pay for the electrical stimulation supplies billed for date of service 
August 27, 2022.  
 
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 lab services provided on September 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One is required 
before alternatives can be considered. 
 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Obinutuzumab. 
 
You asked the Plan to pre-approve Obinutuzumab. You say that Obinutuzumab is medically necessary. The 
Plan denied your request. The Plan says the records do not show a trial of Ruxience. 
 
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 Obinutuzumab. Our reviewer says that 
Obinutuzumab is not medically necessary. Our physician reviewer found the records do not show a failed trial 
of the plan preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Obinutuzumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Obinutuzumab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has atherosclerotic heart 
disease. The records document she is receiving the Plan's preferred alternative but does not document failure of 
intolerance. The requested medication is a new start. The records do not document a trial and failure of the 
preferred drug, Praluent, or that it would be contraindicated or less effective. Leqvio is therefore not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc OR Supartz FX is required before alternatives can be 
considered. 
 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Lupron. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this drug is only Food and Drug Administration (FDA) approved for advanced 
prostate cancer (metastatic). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is medically reasonable or necessary. Our physician reviewer found that Lupron is not FDA 
approved for the enrollee's diagnosis. However, giving androgen deprivation therapy (ADT) before, during, 
and/or after radiation (neoadjuvant, concurrent, and/or adjuvant ADT) prolongs survival in selected radiation-
managed patients. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Lupron.  
 
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.