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

 
We decided that the Plan does not have to pay for the PrismRA test provided on November 4, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
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 on November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical orthosis (L0180) provided on September 27, 
2022. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
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 medical records provided do not indicate anything about the enrollee needing braces. Therefore, we 
decided that the Plan does not have to pay for the cervical orthosis (L0180) provided on September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power arm brace (MyoPro) (L8702). 
 
You asked the Plan to pre-approve a MyoPro power arm brace. You say that this device is the enrollee's best 
opportunity for regaining meaningful use of their left upper extremity. The Plan denied your request. The Plan 
says there is no documentation this device meets but does not exceed the enrollee's needs nor do they indicate 
that the device is appropriate with respect to the enrollees condition. 
 
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 MyoPro power arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that records from the enrollee's treating provider do not clarify why the 
requested device is the most appropriate treatment for the enrollee's condition. In addition, provided records 
report left upper extremity spasticity which may be a contraindication to use of the device. 
 
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 MyoPro power arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power arm brace (MyoPro) (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular recording. 
 
You asked the Plan to pre-approve external mobile cardiovascular recording. You say that the requested 
external mobile cardiovascular recording is medically necessary. The Plan denied your request. The Plan says 
the requested external mobile cardiovascular recording 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 external mobile cardiovascular 
recording. Our reviewer says that the requested external mobile cardiovascular recording is not medically 
necessary. Our physician reviewer found the enrollee has a history of palpitations, and this was the stated 
indication for mobile cardiac outpatient telemetry (MCOT) authorization. As such, guidelines would not 
support a need for MCOT monitoring in this setting. In summary, there was insufficient documentation to 
support the medical necessity for an MCOT monitor 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 external mobile cardiovascular recording have not been met. Therefore, we 
decided that the Plan does not have to pre-approve external mobile cardiovascular recording.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on July 27, 2022, and July 
28, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
procedure code 99233. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99233. 
 
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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of procedure code 99233. Our reviewer found neither progress note contains 
an interval history or high-complexity medical decision making. As such, the billing of CPT code 99233 on 
July 27, 2022, and July 28, 2022, is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on July 27, 2022, and July 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on September 19, 
2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this was coded correctly and should 
be paid. The Plan denied your request. The Plan says modifier -25 is required for G0463. As this was not 
reported, the claim cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims are processed through 
the I/OCE and OCE edits are applied.   
 We looked at the file and Medicare rules. The OCE edit that was applied is number 21. OCE edit 21 is invoked 
when one or more type T or S procedures occur on the same day as a line item containing an evaluation and 
management (EM) code, without modifier 25. Review of the claim shows that a line item containing EM code 
G0463 is reported on this claim, without modifier 25. The claim also has code 71046 which is listed as a Type 
S code. This means that the OCE edit 21 correctly denied the claim. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that 
the Plan does not have to pay for the outpatient hospital services provided on September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G (L8702). 
 
You asked the Plan to pre-approve the MyoPro. You say that the MyoPro is medically necessary. The Plan 
denied your request. The Plan says that this item is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current clinical guidelines for adult stroke rehabilitation and recovery designate robotic 
therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" 
with unproven benefit in the home environment. The provided records document the enrollee has right upper 
extremity spasticity, which requires Botox injections that may be a contraindication to use of the device. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro Motion G (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), electronic 
connection (E2311), and repair or nonroutine service for durable medical equipment other than oxygen 
equipment (K0789).  
You asked the Plan to pre-approve the modifications. You say that the enrollee needs these modifications in 
order to be more independent. The Plan denied your request. The Plan says the requested modifications do not 
have a medical purpose and therefore are not covered. 
 
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 modifications. Our reviewer says 
that the requested electronic connection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee has adequate upper body 
strength to manage multiple standard power switches. Therefore, the reviewer found that the electronic 
connection 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 the modifications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power seat elevation system (E2300), electronic connection (E2311), and repair or 
nonroutine service for durable medical equipment other than oxygen equipment (K0789).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
conditions 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 a spinal cord stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an 
evidence based indication for a spinal cord stimulator trial. The request 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC). 
 
You asked the Plan to pre-approve placement of an LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED) with certain conditions. 
 
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 placement of an LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no history of atrial 
fibrillation. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC 
placement would not be considered reasonable or medically necessary 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 placement of an LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC).
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. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Retacrit. Our reviewer says that the 
documentation does not support that the requested drug meet step therapy criteria. Our physician reviewer 
found the enrollee has a history of anemia due to antineoplastic chemotherapy. The documentation does not 
support that the enrollee has tried and failed Aranesp or Procrit. The documentation does not support that 
Aranesp or Procrit would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
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 pay for the pneumatic compression device provided during 
outpatient surgery on September 15, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this item was issued to the 
patient for use during surgery, so it should be paid. The Plan denied your request. The Plan says durable 
medical equipment used in an outpatient hospital facility is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device provided during outpatient surgery on 
September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical and vaginal cancer screening provided on  
October 12, 2022. 
 
You asked the Plan to pay for cervical and vaginal cancer screening. The Plan denied your request. The Plan 
says that your Plan does not cover more than one routine gynecologist (GYN) visit every 24 months. You have 
reached the limit for this service. 
 
The Plan contract covers cervical and vaginal cancer screening once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you received a routine GYN exam on 
October 5, 2021. You have reached the benefit limit. Therefore, we decided that the Plan does not have to pay 
for cervical and vaginal cancer screening provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 13, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this is a Medicare covered test. The Plan 
denied your request. The Plan says this test is not covered by Medicare and has not been approved by the 
MolDX program. 
 
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 non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 7, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for a compound drug (J7999) provided on October 26, 2022. 
 
You asked the Plan to pay for a compound drug. You say that the compound drug at issue has been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that a corrected claim is needed with NDC 
information. However, the case record supports that NDCs for the compound drug's ingredients have been 
provided to the Plan. The compound drug does not have its own NDC. It is the Plan's responsibility to support 
its denial rationale. In this case, the Plan's denial has not been supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for a compound drug (J7999) provided on October 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual screening for depression provided on  
November 29, 2022. 
 
You asked the Plan to pay for the annual screening for depression. The Plan denied your request. The Plan says 
the enrollee has already received the maximum amount covered for this service. The enrollee previously 
received a depression screening on January 26, 2022. 
 
The Plan contract says that the Plan covers one screening for depression per year. 
 
We looked at the file and the Plans rules. The file shows that you have received the maximum amount covered 
for this service. Therefore, we decided that the Plan does not have to pay for the annual screening for 
depression provided on November 29, 2022.