Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis (Q5104). 
 
You asked the Plan to pre-approve Renflexis. You say that the enrollee was on Inflectra intravenous infusions 
from December 23, 2021, to November 19, 2022, and is currently on Methotrexate. You also say that the 
enrollee has tried and failed Enbrel, Otezla, Humira, and Cosentyx. The Plan denied your request. The Plan 
says this request does not meet the Plan's Part B step therapy criteria for Renflexis. 
 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 Renflexis. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Renflexis. Our physician reviewer found the Plan requires a 
trial of Stelara before they will approve the requested drug. The enrollee has not tried and failed the required 
drug. Our reviewer also found that the documentation does not support that Stelara would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis (Q5104).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 and presumptive drug 
testing billed with code 80307 for date(s) of service September 1, 2022. 
 
You asked the Plan to pay for codes 83789 and 80307. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says codes 83789 and 80307 is not separately 
payable. In addition, the enrollee also had presumptive drug testing provided and billed under code 80305 for 
this same date. Only one presumptive drug testing code is payable per date of service. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. The rules also say that only 
one presumptive drug testing code may be reported per date of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 83789 and 80307 have not been met. Specifically, we find that the testing described by code 
83789 is not separately payable. In addition, the record shows that another presumptive drug testing code 
(80305) has already been reported for this enrollee for this date of service. Therefore, we decided that the Plan 
does not have to pay for validity testing billed with code 83789 and presumptive drug testing billed with code 
80307 for date(s) of service September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0671) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the items can be provided by a network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652) and appliances (E0671) to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in PVT-TgV mode without 
Auto-expiratory positive airway pressure (EPAP) (AE) that could be delivered in bilevel positive airway 
pressure (BiPAP) is not covered. The Plan states that a BiPAP device with AVAPS would meet all the needs 
requested by provider and would be considered for approval if requested. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found the provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability. The Plan has indicated coverage for such a device is available upon request. The elements 
of the coverage criteria are not satisfied.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway pressure 
(CPAP) device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service July 23, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service July 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that you feel this should be covered since your cancer care is 
approved. You also say that you were advised that this item was covered. The Plan denied your request. The 
Plan says the requested item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on August 4, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
We looked at the file and Medicare rules. Payment for procedure code 99284 is included in the global surgery 
payment for the procedure (23650) provided on the same date. Separate payment cannot be made for procedure 
code 99284. Therefore, we decided that the Plan does not have to pay for procedure code 99284 provided on 
August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new continuous positive airway pressure device 
(CPAP). 
 
You asked the Plan to pre-approve the item. You say that it is very uncomfortable to travel with this machine. 
The Plan denied your request. The Plan says you already have the same or similar durable medical equipment 
in good condition and less than five years old. 
 The Plan must follow Medicare rules. Medicare rules say that the typical durable medical equipment (DME) 
reasonable useful lifetime is five years. 
 
The records show that you already have a CPAP device that is less than five years ago. The new device is being 
requested for travel and use outside of the home. Based on this information, we decided that Medicare rules for 
coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
new continuous positive airway pressure device (CPAP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on July 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that additional 
documents have been submitted to prove medical necessity. You believe that these services should be 
considered due to the enrollees past medical history. The Plan denied your request. The Plan says a PCD that 
provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a 
preventative service. Items used for preventative services are excluded from coverage under Medicare. 
Therefore, claims for the requested codes will be denied as no Medicare benefit. 
 The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half 
leg (E0673) provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve analysis for antibody to enterovirus (gastrointestinal 
virus) (86658) to be provided by an out of network provider. 
 
You asked the Plan to pre-approve the laboratory services. You say that this is the only doctor in your area that 
can treat your alcohol brewery syndrome. The Plan denied your request. The Plan says there is insufficient 
evidence that the requested services meet the medically necessary criteria. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
additional medical records were needed to support medical necessity. The records show that the Plan made 
multiple requests to the provider for the needed medical records without success. The requested provider in this 
case is not a network provider with the Plan. The Plan has network providers available who can provide the 
items/services at issue in this appeal. Therefore, we decided that the Plan does not have to pre-approve analysis 
for antibody to enterovirus (gastrointestinal virus) (86658) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that it is crucial for the enrollee to use a non-invasive 
ventilator device that has alarms and a battery backup. The Plan denied your request. The Plan says a ventilator 
is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the enrollee can safely receive the 
services they need in other settings, for example: a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion drugs, supplies, and services. 
 
You asked the Plan to pre-approve home infusion services. You say that you have no way to get medicine into 
your infusion pump and need this provider to come to your home to administer the drugs. The Plan denied your 
request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacies may not bill Medicare Part B 
services under the incident-to provision.  
 
We looked at the file and Medicare rules. These services are not covered when furnished directly by a 
pharmacy provider. Based on this information, we decided that Medicare rules for coverage of home infusion 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve home infusion 
drugs, supplies, and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral nerve block injections (64447 x 2). 
 
You asked the Plan to pre-approve the injections. You say that the bilateral saphenous nerve block is to be used 
as a diagnostic procedure to evaluate for peripheral nerve stimulator implantation. The Plan denied your 
request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that here is insufficient evidence to support the use of 
peripheral nerve blocks in the treatment of diabetic peripheral neuropathy, peripheral neuropathies caused by 
other underlying systemic diseases or peripheral neuropathies causes such as degenerative or idiopathic 
reasons. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not support that these injections are to be used for any of the diagnostic and therapeutic purposes that are 
considered medically reasonable and necessary. Therefore, the reviewer found that the requested injections 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral nerve block injections (64447 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on August 11, 2022. 
 
You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that the treating physician 
determined this service to be medically necessary. The Plan denied your request. The Plan says the number of 
definitive urine drug classes requested are not medically necessary. 
 
The Plan follows 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 definitive UDT for 22 or more drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that definitive 
testing is covered only under certain conditions: When the results of the screen are presumptively positive; 
when the results of the screen are negative and this negative finding is inconsistent with the medical history; or 
when the coverage criteria of the policy are met and there is no presumptive test available, locally and/or 
commercially, as may be the case for certain synthetic or semi-synthetic opioids. This testing does not meet 
these criteria and therefore, the testing was 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 definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion supplies billed for date of service July 1, 
2021, to July 8, 2021. 
 
You asked the Plan to pay for the home infusion supplies. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you have not provided sufficient documentation 
to support payment for these supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, you have provided no documentation related to the shipment, delivery, or receipt of these supplies.  Further, you 
have provided no packing slip or other evidence showing the specific supplies delivered to the patient. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for home infusion supplies billed for date of service 
July 1, 2021, to July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says MyoPro is unproven and not medically 
necessary due to insufficient evidence of safety and/or efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 Motion G orthotic device (L8702).