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

 
We decided that the Plan does not have to pay for the xT genetic testing panel billed with date of service April 
24, 2022. 
 
You asked the Plan to pay for the xT genetic testing. You say that this is medically necessary testing that must 
be covered. The Plan denied your request. The Plan says this was not reported with an appropriate DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that this type of genetic testing would correctly report 
the DOS as the date the services were rendered only when the sample was taken in an outpatient hospital 
encounter, and it was medically appropriate to be taken in this setting.  
 
We looked at the file and Medicare rules. There is no evidence that this peripheral blood sample was drawn in a 
hospital setting. Given that this is routine venipuncture, it does not appear medically appropriate for the sample to be taken in the hospital setting. As such, the testing does not meet an exception to reporting the DOS as the 
date the sample was taken. Based on this information, we decided that Medicare rules for coverage of the xT 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the xT genetic 
testing panel billed with date of service April 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injection (J7321). 
 
You asked the Plan to pre-approve Supartz. You say that the enrollee needs this. The Plan denied your request. 
The Plan says the requested injection is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that viscosupplementation for intra-articular injections of 
the knee are considered reasonable and necessary when all of the criteria have been 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 Supartz. Our reviewer says that the 
Supartz injection is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has symptomatic osteoarthritis of the knee. The reviewer found the documentation 
does not support a trial and failure of at least 3 months of conservative treatment. The reviewer also found the 
documentation does not support failure of or contraindication to intra-articular glucocorticoid injections. 
Therefore, the reviewer found that the requested injection is 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz injection (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged evaluation and management services provided 
on June 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the enrollee was in a nursing home and did not 
have a choice as to which provider saw them. The provider should not be required to obtain authorization to 
treat a nursing home patient. The Plan denied your request. The Plan says these services were provided OON 
without prior authorization. 
 
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 the prolonged evaluation and management 
services provided on June 2, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the drug is not 
medically necessary for the enrollee's condition. 
 
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 Retacrit. Our physician reviewer found 
that the enrollee has stage IV prostate cancer with bone metastases, as well as iron deficiency anemia and 
anemia of chronic disease. The enrollee has been treated with monthly Xgeva along with calcium and vitamin 
D. The requested use of Retacrit is not FDA approved for the enrollee's diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
National Coverage Determination shows that the treatment is not reasonable and necessary for the anemia of 
cancer not related to cancer treatment. The documentation does not support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the continuous positive airway pressure 
(CPAP) device and supplies purchased on December 22, 2021. 
 
You asked the Plan to provide reimbursement for the CPAP device. You say that you feel that this should be 
covered as it was medically necessary. The Plan denied your request. The Plan says you purchased this device 
from a supplier that is not enrolled in Medicare. No payment can be made for these items. 
 
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 provide reimbursement for the continuous 
positive airway pressure (CPAP) device and supplies purchased on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in your clinical 
management. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that given the previously submitted history, physical 
examination and the radiologic findings, the Intraccept procedure is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says Medicare does not cover procedures that are 
experimental or investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided May 20, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this test is medically necessary. The Plan denied 
your request. The Plan says this test is not covered because it is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for readmission to an acute care 
hospital for further functional decline, deep vein thrombosis, pressure ulcers from decreased mobility, and 
cardiac events if therapy isn't received. The Plan denied your request. The Plan says that IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollee is at risk for post stroke complications and inpatient hospitalization for close medical 
monitoring during rehabilitation would be expected. Although the enrollee is currently receiving home health 
care services, the evaluating home health therapists recommend intense therapy including physical and 
occupational therapy. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service 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.  
 
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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. Therefore, the reviewer found 
that the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant patent foramen ovale (PFO) closure device. 
 
You asked the Plan to pre-approve implant PFO closure device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 implant PFO closure device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a stroke in the past and a transesophageal echocardiogram 
has shown probable small PFO without atrial septal aneurysm. Per Risk of Paradoxical Embolism and 
PASCAL scoring, the likelihood of paradoxical embolism as the cause of central retinal artery occlusion is 
small. Anticoagulation is required in any case for prosthetic aortic valve. As such, guidelines would not support 
the need for a PFO closure device. There is insufficient documentation to support the medical necessity for the 
requested PFO closure in this enrollees clinical management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implant PFO closure device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implant patent foramen ovale (PFO) closure device.
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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet the requirements for 
approval. 
 
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 evaluated in an emergency room on September 17, 2022, after a fall 
with a minimally displaced pelvic fracture and was discharged back to her assisted living facility with services. The enrollee has declined functionally since July and now is non ambulatory falling and getting around in a 
wheelchair. The enrollee is medically stable with debility. There are no complex nursing or rehabilitation 
needs. While the enrollee has 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 15, 
2022.  
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  
 
In this case, we have confirmed that code 83789 is a column II code to column I code 80307. While code 
83789 was billed with modifier -59, the medical records provided do not show that the service billed with the  
-59 modifier was a distinct procedural service. 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 83789 billed for date of 
service February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the enrollee has chronic functional loss secondary to chronic medical and orthopedic 
issues. Intensive rehabilitation is not indicated. The underlying chronic orthopedic and medical causes have not 
been resolved limiting the enrollee's capacity to respond to intensive rehabilitation. The enrollee had a course 
of intensive rehabilitation but continued to decline. The enrollee does not have complex rehabilitation needs 
requiring frequent physiatry oversight. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology consult to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that this provider is closer to you. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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. The network provider is located 6.5 miles 
from your residence. 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 cardiology consult to be provided by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kadcyla (J9354). 
 
You asked the Plan to pre-approve the drug. You say that they advised they would not be able to safely perform 
surgery or close the enrollee. The Plan denied your request. The Plan says using this drug before surgery is not 
a supported treatment. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has not 
received prior therapy for metastatic disease or developed disease recurrence during or within six months of 
completing adjuvant therapy. There is insufficient evidence that treatment with Kadcyla is reasonably expected 
to be safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kadcyla (J9354).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) 
coded as E0652. 
 
You asked the Plan to pre-approve the E0652 PCD. You say that the enrollee requires this treatment. The Plan 
denied your request. The Plan says this does not meet LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs coded as E0652 are not covered for 
treatment of CVI.   
 
We looked at the file and Medicare rules. This type of PCD has been requested for a noncovered indication. 
Based on this information, we decided that Medicare rules for coverage of the E0652 PCD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device 
(PCD) coded as E0652.