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

 
We decided that the Plan does not have to pre-approve live tumor cell culture and therapeutic response testing. 
 
You asked the Plan to pre-approve the requested live tumor culture and response testing. You say that it is felt 
that this is needed prior to being seen by the oncologist. The Plan denied your request. The Plan says the 
requested testing is considered experimental. 
 
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 requested live tumor culture and 
response testing. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of stage III breast cancer, 
cervical cancer, and radiation-induced sarcoma. She is seen on a yearly basis as follow-up for these conditions. 
There is no evidence of active disease. The requested testing is not supported as no clinical rationale has been 
provided for this test. The service 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 the requested live tumor culture and response testing have not been met. Therefore, we decided that the Plan does not have to pre-approve live tumor cell culture and therapeutic 
response testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (EO), with adjustable position locking 
joint(s), prefabricated, off-the-shelf (L3761) provided July 8, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the provider ordered by prescription, the elbow 
orthosis and included the applicable office visit notes to show compliance with policy guidelines regarding 
reimbursement for DME. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 orthosis. 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 the physician documentation available for review does not indicate the prescribed 
DME is medically necessary as the enrollee does not have a medical condition to be treated with an elbow 
orthosis.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf 
(L3761) provided July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the hearing aid fitting/checking (V5011). We decided that the Plan does 
not have to pay for the hearing aids (V5261), ear mold/insert (V5264), and dispensing fee (V5160).  
 
You asked the Plan to pay for the hearing aid fitting/checking (V5011), hearing aids (V5261), ear mold/insert 
(V5264), and dispensing fee (V5160) provided on April 13, 2022. You say that you have hearing loss, and this 
hearing aid makes a significant difference for you. The Plan says that a separate benefit is offered from 
Medicare for hearing aids, but you would have to go to a Plan-approved provider and receive the Plan's 
approved hearing aid branded hearing aids. The Plan also says that hearing aid fitting/checking, ear 
mold/insert, and dispensing fee are not covered services. 
 
We decided that the Plan has to pay for the hearing aid fitting/checking (V5011).  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the hearing aid fitting/checking (V5011) by a contract provider. The file does not show 
that the Plan provided notice that the hearing aid fitting/checking (V5011) would not be covered. The Plan 
contract specifically says that you are responsible for a $0 copay for a fitting and evaluation from an in-
network provider. Under Medicare rules, this means the hearing aid fitting/checking (V5011) is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the hearing aid fitting/checking 
(V5011).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We also decided that the Plan does not have to pay for the hearing aids (V5261), ear mold/insert (V5264), 
and dispensing fee (V5160). 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor. 
 
We looked at the file and the Plan's rules. Specifically, the hearing aids (V5261), ear mold/insert (V5264), and 
dispensing fee (V5160) were not rendered by a Plan approved hearing aid vendor. Based on this information, 
we decided that the Plan's rules for coverage of the hearing aids (V5261), ear mold/insert (V5264), and 
dispensing fee (V5160) have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aids (V5261), ear mold/insert (V5264), and dispensing fee (V5160). 
 
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: 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 would benefit from inpatient 
rehabilitation to improve his overall function, mobility, and safety prior to returning home. You say this will 
reduce caregiver burden and reduce the risk of readmission because the enrollee is a high risk for falls and 
infection. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF), home with home 
health services, or home with outpatient therapy. 
 
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 was admitted for surgical repair of a hip fracture. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327) injection (20610). 
 
You asked the Plan to pre-approve Monovisc. You say that you feel that knee replacement surgery seems to be 
a dramatic next step. You say that you would like to get an injection as an alternative. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred drugs, Supartz FX, Hyalgan, Euflexxa, 
and Synvisc One. 
 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 Monovisc. 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 drugs. the reviewer found that 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. 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327) injection (20610).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee is not able to take oral bisphosphonates. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Forteo. 
 
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 Evenity. 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 there is no documentation 
provided indicating that the plans required drug would likely be less effective and/or likely have adverse 
effects for the enrollee. 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness, coronary artery bypass, and valve replacement. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided March 11, 2022, to April 
9, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says an NOA is required to process final. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 11, 2022. an NOA was not submitted in order to process the final 
home health claim submitted. This means that no payment can be made on this claim as billed. Therefore, we 
decided that the Plan does not have to pay for the home health services provided March 11, 2022, to April 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the claim did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 6, 2021, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the services at issue were billed correctly for 
payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 6, 2021, billed 
with code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 25, 2022, billed with 
codes 81276, 81301, 81311, 81191, 81210, 81272, and 81275. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and 
appropriate. 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 
January 25, 2022, billed with codes 81276, 81301, 81311, 81191, 81210, 81272, and 81275.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an unlisted laparoscopic procedure of the liver provided to the enrollee 
on March 17, 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 that this is inclusive to the primary procedure. 
 
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 47379 is "Unlisted laparoscopic procedure, liver." 
 
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 supported by the medical records. Our reviewer found that the medical records support this 
procedure code for a laparoscopic wedge liver biopsy. There is no edit between CPT 47379 and 43775. The 
coding in this case is correct. 
 
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 has to pay 
for an unlisted laparoscopic procedure of the liver provided to the enrollee on March 17, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 3 power wheelchair with multiple power 
options (power tilt and recline) and upgraded electronics coded as K0861, E2300, E2363, E1007, E2311, 
E1012, E0955, E1028, E2377, E2313 and E2601. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that please reconsider the 
documentation provided for the K0861 base & all recommended components, needed to meet the enrollee's 
current medical, mobility & functional needs. The Plan denied your request. The Plan says the enrollee does 
not have a medical need d for the multiple power options included with K0861. The Upgraded electronics 
(expandable controller, harness and electronic connector to 2 power options) are not medically necessary. The 
power elevating leg rests are not medically needed and E2300 does not service a medical purpose. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity.  
 
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 power wheelchair and accessories. 
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 the enrollee has a neurologic disorder with functional 
deficits. The criteria for a power wheelchair are met. The documentation does not indicate that the enrollee has 
any pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or 
recline. The enrollee does not have a documented medical condition that would necessitate power elevating leg 
rests. The requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Although the criteria for a power wheelchair are met, the enrollee does not require the power 
options of the specifically requested power wheelchair. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the group 3 power wheelchair with multiple power options (power 
tilt and recline) and upgraded electronics coded as K0861, E2300, E2363, E1007, E2311, E1012, E0955, 
E1028, E2377, E2313 and E2601.