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

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee can use zoledronic acid. You say that the 
enrollee's insurance denied it saying the enrollee needed to try and fail other drugs. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 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 the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug. The reviewer also found that the documentation does 
not support the zoledronic acid 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 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319 and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 12, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319 and 81294.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
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 CardioMEMs was approved by the 
Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 94761. The Plan denied your request. The Plan says procedure 
code 94761 is considered bundled and 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 procedure code. 
 We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. As another 
payable service (94664 was billed on the same date by the same provider, procedure code 94761 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
94761 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 94761 
billed for date of service February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (coagulation factor V) gene analysis (81241). 
 
You asked the Plan to pre-approve F5 gene analysis. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this test is considered experimental/investigational for any indication other 
than for pregnant women who meet certain conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the F5 gene is non-covered except for 
pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F5 gene analysis have not been met. Specifically, there is no evidence that the enrollee is pregnant, 
and therefore this test is non-covered. Therefore, we decided that the Plan does not have to pre-approve F5 
(coagulation factor V) gene analysis (81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 29, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of Zephyr valves with inpatient level of care. 
 
You asked the Plan to pre-approve Zephyr valves. 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 Zephyr valves. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets clinical criteria for endobronchial valve placement except there is no arterial 
blood gas at rest breathing room air. The resting partial air pressure (PaO2) breathing room air needs to be 
greater than 45mmHg and partial carbon dioxide pressure (PaCO2) less than 60mmHg. Because the criteria are 
not met, the hospital stay is not 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 Zephyr valves have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of Zephyr valves with inpatient level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
December 17, 2021. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a proof of delivery was 
not submitted. 
 
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 an itemized packing slip or proof of delivery for the date of service and supplies 
provided in this case. 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 the durable 
medical equipment (DME) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with codes 92928 and 92978 for 
July 6, 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 procedure codes 92928 and 92978 are not supported. 
 
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 92928 is percutaneous transcatheter placement of 
intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch. The 
definition of code 92978 is endoluminal imaging of coronary vessel or graft using intravascular ultrasound 
(IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention 
including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for 
primary procedure). 
 
We find that CPT codes 92928 and 92978 are not supported in the medical record. Specifically, there is no 
procedure note with details to support that a percutaneous transcatheter placement of intracoronary stent, single major coronary artery or branch, was performed to support code 92928. There is no documentation of a 
procedure note with details to support an endoluminal imaging of coronary vessel or graft using IVUS or OCT 
was performed to support code 92978. 
 
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 pay for the surgical services billed with codes 92928 and 
92978 for July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has obstructive sleep apnea 
(OSA) and severe obesity and has had a home ventilator since about 2015. At that time, he was hospitalized 
with pneumonia and an arterial blood gas (ABG) study was consistent with acute-on-chronic hypercarbic 
respiratory failure. There is no documentation that continuous positive airway pressure (CPAP) or bi-level 
positive airway pressure (BiPAP) have been tried and failed as an outpatient. A home ventilator is not covered 
for the treatment of OSA when used at settings that can be provided with BiPAP. The ventilator is 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 home ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee would greatly benefit from Botox. The 
Plan denied your request. The Plan says the Plan requires a trial of Dysport or Xeomin before it will approve 
Botox. 
 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 Botox. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Botox. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Dysport or Xeomin. The record does not show 
that these drugs would likely be less effective and/or have adverse effects 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 30310 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 30310. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed is not payable as billed. 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 0 for CPT code 30310. This means there 
physician services cannot be split into professional and technical components. In this case, CPT code 30310 is 
a physician services for which payment may not be made when they are provided to hospital inpatients or 
patients in a hospital outpatient department. Based on this information, we decided that Medicare rules for 
coverage of procedure code 30310 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 30310 billed for date of service September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interlaminar stabilization device (22868). 
 
You asked the Plan to pre-approve a Coflex interlaminar stabilization device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Coflex interlaminar stabilization 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature 
do not fully support the spinal decompression device procedure over the gold standard of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 Coflex interlaminar stabilization device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Coflex interlaminar stabilization device (22868).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage implant surgery (D6011) for teeth #19, 
#20, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the Plans authorization of implants 
for teeth #3 & #14. Therefore, we decided that the Plan does not have to pre-approve second stage implant 
surgery (D6011) for teeth #19, #20, and #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for date of service 
October 14, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation did not support the billed code. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the continuous glucose monitor billed for date of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 11, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the documentation 
submitted did not sufficiently support the billed supply code. 
 
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 for the supplies provided in this case. The documentation 
does not contain an itemized packing slip or delivery ticket showing 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 the durable medical equipment (DME) provided 
on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this item. The Plan denied your 
request. The Plan says a CGM is not covered under Medicare if the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. 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 a genicular nerve block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease, osteoarthritis of the knee, as a treatment prior to 
knee replacement, as a treatment following knee replacement, or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.