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

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the heart 
without contrast. 
 
You asked the Plan to pre-approve the CT scan. You say that it is medically necessary for the enrollee to get a 
CT scan done. The Plan denied your request. The Plan says Medicare does not cover the requested study for 
screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
CT scan of the heart is not medically necessary. Our physician reviewer found that it was reported that the 
enrollee had no cardiac symptoms or cardiac history. The enrollee LDL was 194 on recent testing. CT heart 
(calcium scoring) was requested. However, the provided documentation did not clarify what treatment advice 
would change with the calcium score. The enrollee already has high enough cholesterol to be a candidate for 
aggressive lifestyle changes and statin use. The calcium score CT would not likely lead to an improved 
outcome for this enrollee and adds additional radiation. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the heart without contrast.
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 Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of oral bishposphonates and Zoledronic Acid 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 do not show a 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77001 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 77001. The Plan denied your request. The Plan says payment for 
code 77001 is bundled into payment for code 37182.  
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 77001 
is a column II code to column I code 37182. 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 77001 billed for date of 
service August 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 99221. The Plan denied your request. The Plan says payment for 
code 99221 is bundled into payment for code 20206. 
 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 99221 
is a column II code to column I code 20206. 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 99221 billed for date of service July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on August 20, 2022, and 
August 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. If more than one evaluation 
and management (face-to face) service is provided on the same day to the same patient by the same physician 
or more than one physician in the same specialty in the same group, only one evaluation and management 
service may be reported.  
 
We looked at the file and Medicare rules. In this case, E&M code 99232 was billed by a physician of the same 
specialty and of the same group practice as code 99291 billed and paid for the same date of service. As such, 
code 99232 is not payable in this case. 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 services 
(99232) provided on August 20, 2022, and August 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Solu-Medrol. 
 
You asked the Plan to pre-approve Solu-Medrol. You say that the enrollee was intolerant to prednisone and 
needs this for treatment of dermatopolymyositis. The Plan denied your request. The Plan says that the enrollee 
has not had a transplant. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Solu-Medrol. Our reviewer says that 
the enrollee meets criteria for the requested use of Solu-Medrol. Our physician reviewer found Solu-Medrol is 
Food & Drug Administration (FDA) approved for the enrollee's diagnosis of dermatomyositis. The use of 
intravenous (IV) Solu-Medrol is standard in the management of dermatomyositis and other similar neurological 
conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Solu-Medrol have been met. Therefore, we decided that the Plan has to pre-
approve use of Solu-Medrol.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74177 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 74177. You say that this claim was denied in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 20, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 74177 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 74177 billed for date of service 
July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gravity colon hydrotherapy/high enema services received 
June 23, 2022, to July 4, 2022. 
 
You asked the Plan to pay for the gravity colon hydrotherapy/high enema services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested 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 pay for the gravity colon hydrotherapy/high enema 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have chronic constipation and have failed other 
therapies. However, the provided documentation did not include evidence of the services being charged and 
paid from the provider. There was no itemized bill for the colonic services to support this request. Therefore, 
you do not meet criteria for the requested services received. 
 
 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 gravity colon hydrotherapy/high enema services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gravity colon hydrotherapy/high enema 
services received June 23, 2022, to July 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and supplies (E0652, 
E0656, E0667x2). 
 
You asked the Plan to pre-approve a pneumatic compression device and supplies. You say that you disagree 
with the denial and feel that the enrollee's clinical presentation shows the request is appropriate. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested service per Medicare 
guidelines. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and supplies (E0652, E0656, E0667x2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplements provided from June 8, 2022, to June 
14, 2022. 
 
You asked the Plan to pay for the nutritional supplements. The Plan denied your request. The Plan says an 
itemized delivery ticket was not provided. 
 
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.  
 
The record does not contain a valid proof of delivery. The documentation does not contain an itemized delivery 
ticket or packing slip showing that the items in question were delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for nutritional supplements provided from June 8, 2022, to June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet joint (64635) and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), 
lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636)  
You asked the Plan to pre-approve radiofrequency ablation of lumbar paravertebral facet joint nerves. You say 
that the medical records provided support the necessity of the services in dispute. The Plan denied your request. 
The Plan says the medical records and the enrollees noted pain relief does not meet the requirements of the 
given criteria. 
 
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 radiofrequency ablation of lumbar 
paravertebral facet joint nerves. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no 
documentation of greater or equal to 80% relief of pain after 2 diagnostic facet joint/medial branch blocks 
(MBBs). The review has determined that the records do not support that the enrollee meets the medically 
necessary criteria listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of lumbar paravertebral facet joint nerves have not been 
met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet 
joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, each additional facet joint (List separately in addition to code for 
primary procedure) (64636)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 23, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services 
were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for code A0429 is not supported in the medical record. Specifically, code A0429 was 
billed with modifier RW. This is not an appropriate modifier to bill for ambulance services. Based on this 
information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high handle walker with a seat and brakes (E1399). 
 
You asked the Plan to pre-approve a high handle walker. You say that you would like an upright walker to go 
to the gym as well as allow increased ease and comfort on your lower back during ambulation. The Plan denied 
your request. The Plan says you do not meet criteria for approval of the requested walker. During the in-home 
assessment, a new four wheeled walker is suggested for you to use at home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a high handle walker with a seat and brakes (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ambulance transport. 
 
You asked the Plan to pre-approve the ambulance transport. You say that the enrollee would be unsafe to be 
discharged via any other mode other than stretcher. The Plan denied your request. The Plan says your request is 
not medically necessary because the enrollee does not meet the criteria requirements outlined in Medicare rules 
for this service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 ambulance transport. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee was admitted with pathologic fracture from metastatic renal cell carcinoma and was transported via 
stretcher. The record does not indicate that the enrollee's clinical condition is such that other methods of 
transport, such as a stretcher van, are contraindicated or that the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide was required. The record also does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
 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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair (E0168). 
 
You asked the Plan to pre-approve an extra wide/heavy duty commode chair. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the member does not meet the weight 
requirements for this item. 
 
The Plan must follow Medicare rules. The rules say that An extra wide/heavy duty commode chair (E0168) is 
covered for a beneficiary who weighs 300 pounds or more. If an E0168 commode is ordered and the 
beneficiary does not weigh more than 300 pounds, it will be denied as not reasonable and necessary. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, 
we decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair (E0168).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and a durable medical equipment, 
miscellaneous item (E1399). 
 
You asked the Plan to pre-approve a sit to stand fame table and miscellaneous item. You say that you disagree 
with the denial. The Plan denied your request. The Plan says standing frames are considered not medical in 
nature and are not a covered benefit with Medicare or the Plan. 
 
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 frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637) and a durable medical equipment, 
miscellaneous item (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen tablets. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen tablets. The Plan denied your request. The 
Plan says this medication is a non-formulary medication and not covered based on the Plan's Pharmacy and 
Therapeutics Committee guidelines for the coverage of non-formulary medications. 
 
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 Hydrocodone-
Acetaminophen tablets.  
 Benefits for Hydrocodone-Acetaminophen tablets 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiomyopathy risk panel provided on November 11, 
2021. 
 
You asked the Plan to pay for the panel testing. You say that the records prove necessity of the claim. The Plan 
denied your request. The Plan says the services are not covered by Medicare. 
 
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 was requested for screening purposes. Medicare does not cover this testing for 
screening purposes. Furthermore, the panel testing was not billed with a single code as required. Therefore, we 
decided that the Plan does not have to pay for the cardiomyopathy risk panel provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect testing (0012M) provided on May 25, 
2022. 
 
You asked the Plan to pay for CxBladder Detect testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not covered by Medicare as it is still considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure codes 0012M and 0013M for 
CxBladder are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder Detect testing have not been met. Therefore, we decided that the Plan does not have to 
pay for CxBladder Detect testing (0012M) provided on May 25, 2022.