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

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. The Plan denied your request. The Plan says the enrollee has not 
failed at least three months of conservative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Monovisc. Our physician reviewer 
found that the enrollee has a history of bilateral knee pain due to osteoarthritis. X-rays of left hip/knee and right 
knee revealed severe tri-compartmental osteoarthritis of both knees. Intra-articular injections with hyaluronic 
acid (Monovisc) are recommended as a possible option for severe osteoarthritis for those who have not 
responded adequately to recommended conservative treatments (exercise, NSAIDs, and/or Acetaminophen) to 
potentially delay total knee replacement. In this case, the enrollee has not had a course of conservative non-
drug therapy (physical therapy and exercise). The documentation does not support that Monovisc is medically 
reasonable or necessary for the enrollee. The documentation does not support that Monovisc is safe and 
effective 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 laboratory service have not been met. Healthcare Common 
Procedure Coding System (HCPCS) code 87150 (11 Units) remains not supported. The place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting POS 11. Of note, the patient resides in Arizona (AZ), and the billing laboratory is located in New Jersey 
(NJ); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code 87150) provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0321). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the patient's condition 
does not require position of the body in ways not feasible in an ordinary bed; they will require frequent changes 
in body position, but there will not be a need for immediate changes in body position. Additionally, the 
patient's condition does not require special attachments that cannot be fixed and used on an ordinary bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle with bigger wheels. 
 
You asked the Plan to pre-approve a power operated vehicle with bigger wheels. You say that the power 
operated vehicle you have been provided rides too low to the ground and is ineffective in the terrain where you 
live. The Plan denied your request. The Plan says medical necessity rules for the requested durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, Medicare 
does not cover equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power operated vehicle with bigger wheels.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the power wheelchair is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for a power wheelchair have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically reasonable and necessary. Our physician reviewer found 
that you are a 66-year-old male with a past medical history of heart failure, osteoarthritis and chronic hip pain 
with ambulatory dysfunction. Based on the medical records provided there is documentation that you have a 
personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. While there is documentation that the 
your mobility deficit cannot be helped by the use of a walker or a cane, the records provided from your face to 
face examination do not document that your mobility deficit cannot be helped by the use of a manual 
wheelchair. The documentation from the July 15, 2021, face to face encounter states that you do have sufficient 
upper extremity function and needed physical and cognitive capabilities to safely self-propel the wheelchair 
during a typical day. As you would be able to use a manual wheelchair, the requested power wheelchair with 
accessories is not 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
September 8, 2021, to September 18, 2021. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you have had a 15 year 
history with diabetes. You also say the hospital staff was not attentive to your care. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $260 
copayment per day for days 1-4 for in-network inpatient hospital care. The Plan contract also says there is no 
charge after day 4. 
 You have been asked to pay a total of $1,040, which is a $260 copayment for days 1-4 of an inpatient hospital 
stay ($260 copayment x 4 days = $1,040). An inpatient hospital stay falls within the Inpatient Hospital Care 
benefit category. 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 copayments for an inpatient hospital stay 
provided from September 8, 2021, to September 18, 2021.  
 
Your complaint about the hospitals staff and services is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for 3D-rendering with interpretation provided to the enrollee on September 
10, 2021. 
 
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 when an imaging radiologic study is performed and 3D-rendering with interpretation is 
done, reimbursement will be considered as part of the primary radiologic procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested iservices are considered medically reasonable and necessary in this case. Our physician reviewer 
found the report of the magnetic resonance imaging (MRI) study of 9/10/21 details the technique and the 
necessity of 3D rendering and interpretation at a separate work station on this brain perfusion study hence 
meeting the criteria for reimbursement. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
3D-rendering with interpretation provided to the enrollee on September 10, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye surgery services provided on August 27, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for eye surgery services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for eye surgery services provided on August 27, 2021, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on September 15, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The CxBladder testing in this case was billed with code 0013M. This 
is not a covered code for CxBladder testing. 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 
CxBladder testing provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 24, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on October 24, 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. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary and supported by the 
records provided. The Plan denied your request. The Plan says IRF care is not medically necessary. The Plan 
says that care at a skilled nursing facility may be an appropriate alternative discharge for the enrollee. 
 
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 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 
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 enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on November 19, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says your primary care physician confirmed you were not referred for these 
services. You did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan had network providers available who could have provided the items/services at issue in this appeal. 
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network 
services provided on November 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 Liquid CDx provided on October 6, 2021. 
 
You asked the Plan to pay for the Guardant360 Liquid CDx. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that the clinical documentation provided 
did not indicate that tissue-based testing was infeasible or that it has already been completed and did not show 
any actionable mutations. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is covered when specific criteria 
are met.  
 
 
 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 Guardant360 Liquid CDx. Our reviewer 
says that all criteria as listed in the Local Coverage Article have been met. Our physician reviewer found the 
member had stage IV non-small cell adenocarcinoma of the lung. The member had not previously been tested 
with Guardant360 for the same primary cancer. The member was untreated for the primary cancer being tested 
or not responding to treatment. The member was seeking further cancer treatment. There was insufficient tissue 
to complete tissue-based CGP. 
 
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 Guardant360 Liquid CDx have been met. Therefore, we decided that the 
Plan has to pay for the Guardant360 Liquid CDx provided on October 6, 2021.  
 
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 a Group 3 power wheelchair (PWC) with two or more 
power seat options. 
 
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 a Group 3 PWC is covered when specific criteria 
are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the records show that you meet the criteria 
for a Group 3 PWC but do not mete the criteria for multiple power options. There is no clinical documentation 
confirming you are at high risk for skin breakdowns, need bladder self-catheterization, have spasticity, or have 
severe lower extremity swelling (edema). The criteria for the Group 3 PWC with multiple power options are 
not met; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with two or more power seat options.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional x-ray of the humerus provided to the enrollee 
on August 4, 2021. 
 
You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says there is no additional documentation supporting an additional study which was 
billed and remains denied. 
 
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 73060 is "Radiologic examination; humerus, minimum of 
2 views." 
 
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 additional services. Our reviewer says that the additional 
x-ray is not supported in the medical records. Our reviewer found a review of the records showed a single right 
humerus exam - CPT 73060 - done on 8/4/21 which was read by the doctor on 8/5/21. There is no second exam 
in the records. 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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for an additional x-ray of the humerus provided to the enrollee on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tubing with integrated heating element for use with 
positive airway pressure device (A4604), provided on September 1, 2021. 
 
You asked the Plan to pay for the tubing with integrated heating element. You say that this item should be 
covered. The Plan denied your request. The Plan says the items were obtained from a provider who is not under 
contract with the health plan, is not certified for Medicare and was not authorized with the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the tubing with integrated heating 
element for use with positive airway pressure device (A4604), provided on September 1, 2021.