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

 
We decided that the Plan does not have to pre-approve the ExosomeDx Prostate (IntelliScore) test. 
 
You asked the Plan to pre-approve the ExosomeDx Prostate test. You say that the patient is having a lot of 
cardiac issues and a prostate biopsy was recommended, however to avoid doing more harm it was decided that 
a liquid biopsy would be more appropriate. The Plan denied your request. The Plan says the ExosomeDx 
Prostate test does not meet the Medicare LCD coverage criteria. The Plan follows Medicare rules.  
 
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 ExosomeDx Prostate test. Our 
reviewer says that the ExosomeDx Prostate test is not medically necessary. Our physician reviewer found that 
the urology office visit documents a PSA level of 11.684, which is higher than specified in the LCD. The 
ExoDx Prostate Test is indicated for men 50 years of age and older with a prostate-specific antigen (PSA) 2-
10ng/mL, considering an initial biopsy, to help decide if a biopsy is necessary. Based on the elevated PSA, a 
TRUS guided biopsy of the prostate was 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 ExosomeDx Prostate test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the ExosomeDx Prostate test.
Appeal type: Step-Therapy
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 you have osteoarthritis and have bone on bone pain 
with every step. You say that you need this for pain and recovery. The Plan denied your request. The Plan says 
the records do not show you've tried one of the preferred drugs or that you have medical reasons that prevent 
you from using one of them. 
  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 the 
elements of the coverage criteria are not satisfied, and this medication cannot be recommended. Our physician 
reviewer found that the provided records do not indicate that you have tried and failed the Plan's preferred step 
one alternative. The record does not indicate that you have a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical laparoscopy (38572) provided on January 3, 
2022. 
 
You asked the Plan to pay for the surgical laparoscopy (38572). You say that the procedure is documented in 
the note. You say that the documentation should be reviewed, and the claim reprocessed accordingly. The Plan 
denied your request. The Plan says this procedure is considered inclusive to CPT code 51999. 
 
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 38572 is laparoscopy, surgical; with bilateral total pelvic 
lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple. 
 
  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 surgical laparoscopy (38572). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the pelvic lymph node dissection would be performed in addition to the cystoprostatectomy and orthotopic 
neobladder urinary diversion. Therefore, separate billing is inappropriate in this case. 
 
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 surgical laparoscopy (38572) have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical laparoscopy (38572) provided on January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27130, 29863 and 27054 billed on February 
6, 2022. 
 
You asked the Plan to pay for procedure codes 27130, 29863 and 27054. The Plan denied your request. The 
Plan says procedure codes 27130 and 29863 are not supported by the medical records submitted. The Plan also 
says an appropriate modifier was not billed with 27054 to bypass the edit. 
 
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 27054 is a column II code to column I code 27130. Procedure code 
27054 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. 
  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 procedure codes 27130 and 29863. Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes a hip bipolar arthroplasty and there is a more appropriate code to report for this 
service. Since the operative report describe a hip arthroscopy, procedure code 29863 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 27130, 29863 and 27054 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 27130, 29863 and 27054 billed on February 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested item 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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc NP allograft procedure. 
 
You asked the Plan to pre-approve a VIA Disc NP allograft procedure. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested procedure is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VIA Disc NP allograft procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the VIA disc allograft is experimental. More research is needed to show 
safety and efficacy before coverage can be approved. 
 
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 VIA Disc NP allograft procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a VIA Disc NP allograft procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested spinal cord stimulator. 
 
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 pre-approve a spinal cord stimulator. Our reviewer 
says that the enrollee meets criteria for the requested spinal cord stimulator. Our physician reviewer found the 
records show that the enrollee has chronic back pain and has had 2 surgeries. No more surgery can be done. 
There have been ample conservative measures to include multiple injections. The psych consult has been done. 
Criteria for the requested stimulator are met. 
 
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 spinal cord stimulator have been met. Therefore, we decided that the Plan has 
to pre-approve a spinal cord stimulator.  
 
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 power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that this device is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollees condition can be improved by a walker, cane or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power mobility device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Phesgo. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has human epidermal 
growth factor receptor 2 (HER2)-positive breast cancer and end-stage chronic obstructive pulmonary disease. 
Based on the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that the Phesgo at issue in this case meets Medicare criteria for medically reasonable and 
necessary. Provided records do not document that the Phesgo will be used with other chemotherapeutic agents 
or be used for metastatic disease or for neoadjuvant or adjuvant treatment. 
 
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 Phesgo.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC Hematology Profile provided on October 29, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX 
program and is medically necessary for this patient. The Plan denied your request. The Plan says that there are 
Medicare coverage determinations which indicate that panels that include FANCC and BLM genes are 
noncovered. 
 
Medicare rules say that molecular diagnostic laboratory tests such as TEST NAME are subject to the MolDX 
application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate 
and unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are noncovered, we find there is no basis to overrule the specific coverage decision made by the 
MolDX contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC Hematology Profile provided on October 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that this ventilator is medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was successfully treated with bilevel positive airway pressure (BiPAP). The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support capability. The plan has indicated coverage for such a device is available upon 
request. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid capsules. 
 
You asked the Plan to pre-approve Nuplazid capsules. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Nuplazid capsules are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Nuplazid capsules.  
 
Benefits for Nuplazid capsules may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable for your condition. 
The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your medical needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator (63650), 
and implantable neurostimulator (L8680). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the requested services 
are medically necessary. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that payment may not be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions have been 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 the durable medical equipment (DME). 
Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found the provided 
documentation indicates that the enrollee did not get adequate relief with a spinal cord stimulator trial. 
Therefore, the reviewer found that the implantable stimulator criteria have not been met. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator (63650), and 
implantable neurostimulator (L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (64451). 
 
You asked the Plan to pre-approve the injection. You say that the requested injection is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested injection 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 injection. Our reviewer says that the 
requested sacroiliac (SI) joint injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate physical examination of three or more 
positive tests results. The reviewer found that the clinical value and effectiveness of an sacroiliac (SI) joint 
injection in the absence of tenderness and negative provocative testing results have not been demonstrated in 
the peer-reviewed literature. Therefore, the reviewer found that the requested injection is 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection (64451).