Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injections. 
 
You asked the Plan to pre-approve PRP injections. You say that the clinical information provided supports the 
need for the requested services. The Plan denied your request. The Plan says the service being requested is not 
a covered benefit. 
 
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 PRP injections. Our reviewer says that 
platelet rich plasma injections are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a ganglion cyst on the left thumb. The provider plans for PRP 
injection into a carpometacarpal joint, in addition to thumb arthroscopy and fat grafting. The treating provider 
acknowledges the experimental nature of PRP use in the context of a ganglion cyst of the thumb. Based on the 
additional information available, the request does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PRP injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma (PRP) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee wedge pillow. 
 
You asked the Plan to pre-approve a knee wedge pillow. You say that you have a fractured kneecap and cannot 
use a regular pillow for support. The Plan denied your request. The Plan says a knee wedge pillow is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. A knee wedge pillow is a self-help item and does not serve a purpose that is primarily 
medical in nature. This item is available to the general public and would be helpful even to those who are not 
sick or injured. Therefore, we decided that the Plan does not have to pre-approve a knee wedge pillow.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing provided on June 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the results of the testing allow physicians to 
make treatment decisions. The Plan denied your request. The Plan says the services were billed with incorrect 
coding. 
 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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the pharmacogenetic testing provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 the drug testing services provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating combination tilt/recline feature and 
electronic connection device for a power mobility device. 
 You asked the Plan to pre-approve power seating tilt/recline and electronic connection device.. You say that the 
enrollee needs these functions to address his chronic conditions. The Plan denied your request. The Plan says 
the denial of authorization for these features is correct, because the enrollee does not meet criteria for a 
tilt/recline system and has good upper extremity strength and function which are adequate to control power 
options. 
 
The Plan must follow Medicare rules. Medicare rules say that a power tilt/recline system may be covered if 
certain criteria are met. 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 power seating tilt/recline and electronic 
connection device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee is 
at high risk for development of an ulcer, utilized intermittent catheterization for bladder management, or needs 
a power seating system to manage increased tone or spasticity. The enrollee's strength in the upper extremities 
should be sufficient to control any power options through their own switches, so an electronic connection 
device is not 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 power seating tilt/recline and electronic connection device. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seating combination tilt/recline 
feature and electronic connection device for a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the evidence clearly supports the use of the Intracept 
procedure and it is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because studies have not proven that this service is helpful for 
treatment of the enrollee's 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy of 
the Intracept procedure for low back pain. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening panel (81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided on March 2, 2021.

You asked the Plan to pay for a hereditary cardiovascular screening panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening panel (81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this for travel. The 
Plan denied your request. The Plan says duplicate items are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a standard oxygen stationary concentrator. a standard oxygen stationary 
concentrator serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the finger prosthesis (L7499). 
 
You asked the Plan to pre-approve the prosthesis. You say that you are asking for reconsideration of the denial. 
The Plan denied your request. The Plan says this request is considered primarily for vocational purposes and 
for leisure activity and does not serve a medical purpose. 
 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. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the finger prosthesis (L7499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you had surgery October 2020 and 
had a blood clot in your left knee which lead to compartment syndrome. You are being advised by your doctor 
that you must wear compression stockings for the rest of your life. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer for the enrollee. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Injectafer for the enrollee.  
 
Benefits for Injectafer may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One for the enrollee. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary for the patient's 
osteoarthritis. The Plan denied your request. The Plan says that there is no indication their preferred agents 
would likely be less effective, and/or cause adverse effects for the member. 
 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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary for the enrollee. The member has not tried and failed the 
Monovisc and Orthovisc. There is no indication that the plan's preferred agent(s) would likely be less effective, 
and/or cause adverse effects for the member. Our physician reviewer found that the enrollee's condition does 
not meet step therapy criteria for Gel-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81401, 81403, 81405, 81406, 81407, 
81408, 81479) provided on January 12, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81401, 81403, 81405, 81406, 81407, 81408, 81479) 
provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care as you are a fall risk and are not 
able to live on your own. You need additional treatment to get back to normal. The Plan denied your request. 
The Plan says the criteria for admission to an IRF are not met. The services you need can be provided 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic CT colonography (74261). 
 
You asked the Plan to pre-approve a diagnostic CT colonography. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 diagnostic CT colonography. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has been informed of the risk of colon cancer with the results of the positive 
Fecal Immunochemical Test (FIT) and of the need for colonoscopy. The enrollee still adamantly refuses direct 
colonoscopy. Such refusal does not constitute the medical necessity of CT colonography. There are no 
contraindications such as prior incomplete colonoscopy or bleeding disorder to qualify for CT colonography. 
 
 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 diagnostic CT colonography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a diagnostic CT colonography (74261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the power operated vehicle (K0800) 
purchased from the out-of-network (OON) provider on June 2, 2021. 
 
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 this item was rendered by an out of network 
provider, without prior authorization. Additionally, scooters to be used outside the home are not covered by 
Medicare.  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. Additionally, Medicare will pay for durable medical equipment 
that is needed for use in the home. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item at 
issue. Additionally, Medicare does not cover durable medical equipment for use outside the home. Therefore, 
we decided that the Plan does not have to issue reimbursement for the power operated vehicle (K0800) 
purchased from the out-of-network (OON) provider on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair. 
 
You asked the Plan to pre-approve a lightweight manual wheelchair. You say that a lightweight manual 
wheelchair is medically necessary. The Plan denied your request. The Plan says your physician did not respond 
to several requests for medical records to support your appeal. Without medical records the Plan cannot 
determine if you meet the criteria needed for this equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Insufficient medical records or physician input has been provided to determine this 
equipment meets Medicare coverage criteria. Therefore, we decided that the Plan does not have to pre-approve 
a lightweight manual wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nineteen (19) additional ST visits. 
 
You asked the Plan to pre-approve nineteen (19) additional ST visits. You say that additional speech therapy is 
medically necessary. The Plan denied your request. The Plan says additional speech therapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 

 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 nineteen (19) additional ST visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health 
Plan. The enrollee has had prior therapy of 19 outpatient visits and the records do not demonstrate that the 
unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a 
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nineteen (19) additional ST visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve nineteen (19) additional ST visits.