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

 
We decided that the Plan does not have to pre-approve oncology (prostate) gene expression profile by real-time 
RT-PCR of 3 genes (ERG, PCA3 and SPDEF) urine algorithm reported as risk score -ExoDx Prostate Test 
(CPT code 0005U). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the lack of peer-reviewed literature, screening for prostate cancer using ExoDx testing 
has not been proven medically effective and is considered 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that this enrollee has had a prior prostate biopsy. As such, ExoDx testing in 
this case is not medically reasonable and necessary. On October 10, 2019, Medicare Administrative Contractor 
(MAC) issued a final LCD L37733, covering the ExoDx Prostate test for men who are being considered for an 
initial prostate biopsy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3 
and SPDEF) urine algorithm reported as risk score -ExoDx Prostate Test (CPT code 0005U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 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 February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve ablation (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this treatment is considered experimental or investigative. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested intracept intraosseous basivertebral nerve ablation at L3, L4, and L5, in this case, is not medically 
reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve basivertebral nerve ablation (CPT code(s): 64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis provided on October 11, 2021. 
 
You asked the Plan to pay for the ankle orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item is not payable as billed. 
 
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 CPT code L1902 is not supported in the medical record. Specifically, this code was billed without 
the required RT (right side) or LT (left side) modifier. Without this required modifier the claim is not payable. 
Based on this information, we decided that Medicare rules for coverage of the ankle orthosis have not been 
met. Therefore, we decided that the Plan does not have to pay for the ankle orthosis provided on October 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiac screening 81401, 81403, 81404, 81405, 
81406, 81407, 81408, 81479 provided November 3, 2021. 
 You asked the Plan to pay for the genetic screening. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says screening 
genetic testing is not a covered benefit. 
 
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, the genetic screening, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for hereditary cardiac screening 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479 provided November 
3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseus nerve ablation of the BVN (CPT 
code 64628). 
 
You asked the Plan to pre-approve the services. You say that you had this procedure and had good results. You 
state that your doctor has given you several different shots that do not work; therefore, the operation would be 
the best option. The Plan denied your request. The Plan says there is no medical necessity for the intracept 
intraosseus nerve ablation of BVN. The evidence is weak to support the efficacy of this procedure. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested intracept intraosseous nerve ablation 
at L1-2 and L2-3, in this case, is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intracept intraosseus nerve ablation of the BVN (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for insulin pump supplies provided from 
February 4, 2022, to February 10, 2022. 
 
You asked the Plan to waive the coinsurance for the insulin pump supplies. You say that the diabetic supplies 
should have no cost. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies, including diabetic supplies. 
 
Item Allowed Amount 20% Coinsurance 
Insulin Pump Syringes (A4225) $90.30 $18.06 
Infusion Set (A4230) $360.00 $72.00 
Total:  $90.06 
 
 You have been asked to pay $90.06, which is 20% of the allowed amount for the insulin pump supplies. The 
insulin pump supplies fall within the Durable Medical Equipment (DME) and Related Supplies benefit 
category. Please note that only diabetic testing supplies are not subject to cost sharing. 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 coinsurance for insulin pump supplies provided from February 4, 2022, to February 
10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1018) provided 
March 16, 2022. 
 
You asked the Plan to pay for the nerve stimulator device. You say that the enrollee has been using the Cala 
Trio device and seeing improvement and control over his hand essential tremor. The Plan denied your request. 
The Plan says the medical effectiveness of such therapy has not been verified by scientifically controlled 
studies. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nerve stimulator device have not been met. Therefore, we decided that the Plan does not have 
to pay for the Cala Trio nerve stimulator device (K1018) provided March 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (CPT code J7327). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from your prescriber that shows you have 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 the medication. Our physician reviewer 
found 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monovisc (CPT code J7327).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 26 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the additional visits are not reasonable or necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
patient has had prior approved therapy and the documentation does not reveal that the patient's requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist without 
evidence of the outcome of the 10 approved sessions and evidence of ongoing need.  The requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the patient's current condition or to 
prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 26 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has continued poor appetite and 
weight loss. You state the enrollee has tried/failed Remeron, so the request is for coverage Dronabinol to help. 
The Plan denied your request. The Plan says the appeal for Dronabinol does not meets Medicare criteria for 
coverage under Part B. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. The enrollee's diagnosed with 
abnormal weight loss. The enrollee does not meet criteria for Part B and they are not being administered 
Dronabinol with cancer chemotherapy treatment that is initiated within 2 hours of the administration of 
chemotherapy and continued for a period not to exceed 48 hours from that time and is not used as a full 
therapeutic replacement for IV anti-emetic drugs that would have been administered at the time of the cancer 
chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve Dronabinol.  
 
Benefits for the medication 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with cervical spine injury and traumatic brain injury 
following an all-terrain vehicle accident. The record indicates that the enrollee is improving but still requires 
acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that she would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that she would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status. The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 13, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the device is used in facility for the 
prevention of thrombotic events. The Plan denied your request. The Plan says the place of service is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the device at issue was provided in an ambulatory surgical center. Medicare rules say that CMS 
does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility 
must furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers.  This service was provided via arrangement of the facility. Payment for this service would have been included 
under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the pneumatic compression device provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenetic testing (81479) provided August 18, 2021. 
 
You asked the Plan to pay for the pharmacogenetic testing. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a pharmacogenomics testing service 
providers must report 1 unit of the appropriate CPT code and enter the appropriate DEX Z-Code. 
 
We looked at the file and Medicare rules. The claim did not include an appropriate Z-code. Based on this 
information, we decided that Medicare rules for coverage of the pharmacogenetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing (81479) provided August 
18, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.