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

 
We decided that the Plan does not have to pay for the AlloSure Heart testing provided on December 17, 2021. 
 
You asked the Plan to pay for the AlloSure Heart testing. You say that the AlloSure Heart testing provided on 
December 17, 2021, was medically necessary. The Plan denied your request. The Plan says the enrollee did not 
meet criteria for the AlloSure Heart testing provided on December 17, 2021. 
 
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 AlloSure Heart testing. Our reviewer says 
that the AlloSure Heart testing provided on December 17, 2021, was not medically necessary. Our physician 
reviewer found the AlloSure test is described as a blood test designed to detect the presence of donor cell-free 
DNA in the recipients blood as a measure of the probability of rejection in heart transplant recipients. The 
enrollee had a heart transplant in 2020. There is no documentation provided to support the basis for the testing. 
As such, there is no evidence to support its role in this enrollee's clinical management. In summary, the 
provided testing was not considered 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 the AlloSure Heart testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the AlloSure Heart testing provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SmartDrive power assist device (E1399) repair. 
 
You asked the Plan to pre-approve a device repair. You say that you already have the attachment. You say that 
you need the rubber bumpers to be replaced. You say that these help you to push yourself uphill and when you 
get tired. The Plan denied your request. The Plan says you have not completed a Qualified Rehabilitation 
Professional Evaluation to determine type of wheelchair is best for you. 
 
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 device repair. Our reviewer says that 
the requested device repair is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not support that this device was furnished in a setting 
appropriate to your medical needs and condition; ordered and furnished by qualified personnel; and meets, but 
does not exceed, your medical need. The documentation indicates that you are using this Smart Drive outside 
on rough terrain. The documentation is not clear that you require the Smart Drive to participate in mobility 
related activities of daily living (MRADLs) in the home. The reviewer also found that the documentation does 
not reveal that a therapist evaluation was performed to supporting that you can safely use this device. Therefore, the reviewer found that the requested device repair is not medically necessary at this time. 
 
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 device repair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SmartDrive power assist device (E1399) repair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolin R. 
 
You asked the Plan to pre-approve Novolin R. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered 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 Novolin R.  
 
Benefits for Novolin R 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 genetic testing provided on May 2, 2022. 
 
You asked the Plan to pay for the genetic testing billed. 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 
May 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided from January 19, 2022, to 
January 28, 2022. 
 You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says separate 
payment cannot be made for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that all services billed by the SNF (including those 
furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are 
included in the SNF's Part A bill.  
 
We looked at the file and Medicare rules. Payment for the requested therapy services are included in the SNF 
payment and are not separately billable or payable. Based on this information, we decided that Medicare rules 
for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to 
pay for the therapy services provided from January 19, 2022, to January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 87591 rendered on January 27, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted does not support two units of CPT 87591. 
 
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 87591 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Neisseria gonorrhoeae, amplified probe technique." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
support an additional unit of CPT 87591. Only gonorrhea/neisseria gonorrhoeae was performed. In this case, 
the additional unit billed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 87591 rendered on January 27, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation facility (IRF) is medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 
an IRF. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the requested IRF admission is not medically necessary. 
 
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 that IRF care is not medically necessary for post hip fracture rehabilitation. The 
enrollee does not require frequent physiatry oversight and has a good post-operative functional status weight 
bearing as tolerated 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 an acute inpatient rehabilitation facility (IRF) admission and 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 enrollee is medically stable, will decline further 
remaining in the hospital and would benefit from a comprehensive inpatient rehabilitation program prior to 
returning home. The Plan denied your request. The Plan says the enrollee's nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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. Our 
physician reviewer found that the enrollee is medically stable, and does not need physician supervision three 
times a week in the IRF. There are no acute rehab or nursing needs identified or documented. With severe 
dementia, the enrollee does not need intensive therapies consisting of at least three hours of therapy per day, at 
least five days a week with a multidisciplinary approach in an IRF. The carry over from learned tasks is highly 
questionable. It is unlikely that the enrollee will make a significant functional recovery in an IRF in a 
reasonable period of time with baseline dependency functionally. Care can be provided in a lower intensity and 
alternate setting, such as a skilled nursing facility (SNF). 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of procedure code 87481 rendered on June 2, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there are no results for all billed units of service. 
 
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 87481 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported five units; 
however, the laboratory report only supports Candida Lusitaniae and Candida Dubliniensis. Therefore, the 
units billed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for five units of procedure code 87481 rendered on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone biopsy. 
 
You asked the Plan to pre-approve a bone biopsy. You say that the records provided support the need for the 
services which remain in dispute. The Plan denied your request. The Plan says a bone biopsy 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. Medicare rules also say that a physician shall not unbundle services that are integral 
to a more comprehensive procedure. 
 
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 bone biopsy. Our reviewer says that a 
bone biopsy is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the requested bone biopsy is essentially part of the approved procedure. The peer-reviewed literature supports a 
bone biopsy to be performed during the percutaneous vertebral augmentation. The documentation does not 
indicate that this would be a separate procedure. Therefore, the requested a bone biopsy, 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 a bone biopsy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone biopsy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical necessity criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services are not medically reasonable or necessary. Our physician reviewer found that based upon a review of the records provided it was not expected this enrollee would improve in a reasonable period of time 
for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. 
The patient was not showing any acute threats to safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as the enrollee did not have dangerousness to self or others. The health plans denial of 
continued inpatient psychiatric services is appropriate. 
 
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 inpatient mental health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 You asked the Plan to pre-approve PTA. You say that the enrollee has a cardiac blockage that this procedure 
will help. The Plan denied your request. The Plan says the records do not show that the enrollee has a cardiac 
lesion amenable to angioplasty. 
 
The Plan follows Medicare rules. Medicare rules state that PTA may be covered under certain conditions. 
 
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 PTA. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found a stress test showed borderline 
ischemia and the enrollee was seen in February 2023 with the plan for cardiac catheterization; however, there is 
no documentation that the study showed any lesions amenable to PTA. Guidelines do not support a need for 
PTA in this setting. As a result, at this time PTA would not be considered 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 PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous transluminal angioplasty (PTA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Mvasi. 
 
You asked the Plan to pre-approve Mvasi. You say that the enrollee is not a candidate for other treatments. The 
Plan denied your request. The Plan says this request is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Mvasi. Our reviewer says that the 
enrollee does not meet criteria for Mvasi. Our physician reviewer found Mvasi is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Mvasi.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 21, 2022, billed with 
codes 93970 and 93923. 
 
You asked the Plan to pay for an extremity study and a complete ultrasound study of arm and leg arteries. You 
say that the claim should be paid as billed. The Plan denied your request. The Plan says some of the billed 
services were approved on the appeal; however, procedure codes 93970 and 93923 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 codes 93970 and 93923 consists of a complete bilateral duplex 
scan of extremity veins with responses to compression and other maneuvers, and complete ultrasound study of 
arm and leg arteries. 
 
 
  
 
 
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 medical services as billed. Our reviewer says that the 
documentation does not support procedure codes 93970 and 93923. Our reviewer found that the procedure 
report does not provide clear documentation to support the extremity study and the complete ultrasound study 
of arm and leg arteries billed was provided. In terms of CPT 93923, the record does not contain evidence that a 
complete physiologic study of bilateral extremities was performed. The exam performed on the lower extremity 
arteries is captured with approved code 93925. No additional code is warranted. In terms of CPT 93970, the 
documentation shows that the venous doppler performed was a limited study, not a complete study. There is a 
more specific code to report for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an extremity study and a complete ultrasound study of arm and leg arteries have 
not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
March 21, 2022, billed with codes 93970 and 93923.