Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled services by a licensed nurse (RN only) for 
management and evaluation of a non-skilled plan of care, each 15 minutes (G0162) electronic analysis of 
programmable, implanted pump for intrathecal or epidural drug infusion (62370) and injection, morphine 
sulfate, preservative-free for epidural or intrathecal use, 10 mg (J2274) provided February 18, 2022. 
 
You asked the Plan to pay for the home infusion services. You say that it is medically necessary the person 
doing the refill be a medical professional with the training to refill pumps and be able to handle life threatening 
mishaps. The Plan denied your request. The Plan says the procedure code is inconsistent with the provider 
type/specialty. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the records do not show 
that there is a valid physician order. Therefore, we decided that the Plan does not have to pay for the skilled 
services by a licensed nurse (RN only) for management and evaluation of a non-skilled plan of care, each 15 
minutes (G0162) electronic analysis of programmable, implanted pump for intrathecal or epidural drug 
infusion (62370) and injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 
(J2274) provided February 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for OVA1 Oncology (ovarian), biochemical assays of five proteins (CA-
125, apoliproprotein A1, beta-2 microglobulin, transferrin and pre-albumin), utilizing serum, algorithm 
reported as a risk score (81503) provided April 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that CPT 81503 was medically necessary. 
Please find abnormal lab test results on 3/11/22 and document that referred patient to oncologist. Please review. 
 The Plan denied your request. The Plan says that multi marker serum tests related to ovarian cancer testing are 
non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the FDA 510K decision summary, the Ova1 test is intended for women greater 
than or equal to 18 years of age who present with an ovarian adnexal mass for which surgery is planned and 
who are not yet referred to an oncologist. The assay is intended for use as a prognostic indicator of a womans 
likelihood that malignancy is present when the physicians independent clinical and radiological evaluation 
does not indicate malignancy. The test is not intended to be used as a screen or standalone diagnostic assay and 
is intended for use in conjunction with imaging studies and clinical assessments in women for whom surgical 
intervention is planned. The records show that the requirements for Medicare coverage are 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 the laboratory services have been met. Therefore, we decided that the Plan has 
to pay for OVA1 Oncology (ovarian), biochemical assays of five proteins (CA-125, apoliproprotein A1, beta-2 microglobulin, transferrin and pre-albumin), utilizing serum, algorithm reported as a risk score (81503) 
provided April 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve Venofer. You say that the requested Venofer is medically necessary. The 
Plan denied your request. The Plan says the requested Venofer is not medically necessary. 
 
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 Venofer. Our reviewer says that the 
requested Venofer is not medically necessary. Our physician reviewer found the enrollee is not anemic and has 
normal iron studies as of August 31, 2022. The use of IV iron is not indicated at this time. 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 Venofer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Venofer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this item is medically 
reasonable and necessary. The Plan denied your request. The Plan says this is considered 
experimental/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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
27, 2021. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says settings that could 
be delivered by a BiPAP device is not covered. 
 
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 a ventilator. Our physician reviewer 
found that the enrollee has chronic obstructive pulmonary disease, unspecified, with chronic respiratory failure, 
unspecified whether with hypoxia or hypercapnia. It is documented that the enrollee could not tolerate CPAP 
and does not want to use it. The documentation supports a diagnosis of severe chronic COPD with chronic 
oxygen-dependent respiratory failure. The documentation does not support that BiPAP has been trialed and 
failed. The documentation does not demonstrate that the BiPAP machine is not appropriate 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint denervation (64636 x 2, 64635 x 2). 
 
You asked the Plan to pre-approve the facet joint denervation. You say that the services are medically 
necessary. You say that they should be covered because the enrollee was diagnosed with advanced 
degenerative disc disease in 2012 and their pain level fluctuates. The Plan denied your request. The Plan says 
the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent 
improvement in the ability to perform previously painful movements and ADLs. 
 
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 facet joint denervation. Our 
reviewer says that the coverage criteria for facet joint denervation have not been met. Our physician reviewer 
found the provided documentation does not address the degree and duration of pain relief achieved after the 
enrollee's last radiofrequency ablation (RFA). Therefore, the reviewer found that the criteria for coverage 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 the facet joint denervation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint denervation (64636 x 2, 64635 x 2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional mammography services provided to the enrollee 
on February 16, 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 two duplicate records have been provided, but there is no indication that additional performed or 
ordered for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that duplicate services are not supported in the medical record. Specifically, there is no evidence that 
multiple exams were ordered or performed on the denied date of service. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for additional mammography services provided to the enrollee on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on February 22, 
2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
March 24, 2022 billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Genomic Testing Cooperative (GTC) Hematology Profile testing 
provided May 28, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile testing. You say that this test was approved by the 
MolDX program and is medically necessary for this enrollee. The Plan denied your request. The Plan says that 
there are Medicare coverage determinations which indicate that panels including the FANCC and BLM genes 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile testing have been met. Based on this information, we decided that 
Medicare rules for coverage of the GTC Hematology Profile testing have been met. Therefore, we decided that 
the Plan has to pay for the Genomic Testing Cooperative (GTC) Hematology Profile testing provided May 28, 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on February 2, 2022, 
February 4, 2022, February 8, 2022, February 10, 2022, February 14, 2022, February 21, 2022, February 25, 
2022, and February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that services were provided to the enrollee 
in good faith, and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider, and a prior authorization request was denied. The Plan 
directed the enrollee to seek care from an in-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 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 physical therapy services provided on 
February 2, 2022, February 4, 2022, February 8, 2022, February 10, 2022, February 14, 2022, February 21, 
2022, February 25, 2022, and February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the hearing aids (V5261) purchased on February 11, 
2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the hearing aids at issue are not payable 
as they were purchased from an out-of-network provider. 
 
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 does not say in clear and accurate terms 
that hearing aids purchased from an out-of-network provider will not be paid for by the Plan.  
 
We looked at your contract with the Plan. We did not see where the contract says that hearing aids purchased 
from an out-of-network provider will not be paid for by the Plan. The Plan contract states that supplemental 
hearing aids should be obtained from a provider in the Plans hearing vendor network but also states that there 
is a $700 allowance per hearing aid device every three years from an in-network or out-of-network provider. 
Therefore, the contract language is not clear and is therefore considered ambiguous. This means that the Plan 
did not follow Medicare rules for disclosure of contractual information. Therefore, we decided that the Plan has 
to issue reimbursement for the hearing aids (V5261) purchased on February 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan for the enrollee. 
 
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered for initial diagnosis/staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when 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 pre-approve a PET scan. Our reviewer says that a 
PET scan is not medically reasonable and necessary. PET scan for the initial staging of prostate cancer is not a 
standard of care. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of a PET scan. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan for the enrollee.
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 a stroke. 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.