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

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
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 SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's clinical presentation was not readily consistent with Parkinson's Disease. Rather, 
it was most consistent with essential tremor. This was demonstrated by their response to therapy with 
propranolol (leading to resolution of their tremor). In such a case where a clinical diagnosis can be established 
based on exam/therapy alone, the requested service would otherwise exceed the enrollee's clinical needs. 
 
   
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee scooter and related sales tax you purchased on 
August 27, 2021. 
 
You asked the Plan to pay for the knee scooter and sales tax. You say that the network providers did not have 
the item you needed and it was more cost effective to purchase it since you were going to have two separate 
surgeries. The Plan denied your request. The Plan says you purchased this item from an ineligible provider. 
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. A 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 pay for the 
knee scooter and related sales tax you purchased on August 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed and Venofer is required before alternatives can be considered. 
 
 
 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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
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 home ventilator. 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. 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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is inadequate documentation that the ventilator at issue meets Medicare criteria for medically 
necessary and reasonable for this enrollee. Provided records document the ventilator is to be used in volume 
assured pressure support mode which could be provided by a bilevel positive airway pressure (BiPAP) device 
with a backup rate and average volume assured pressure support.  As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve iTind urology procedure. 
 
You asked the Plan to pre-approve iTind urology procedure. 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 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 iTind urology procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found iTind is not medically reasonable and necessary in this case. Further studies are 
needed to evaluate the durability of iTind outcomes over a longer follow-up, to better define the indications of 
this approach, and to demonstrate the advantages of second-generation device over the first device. ITind is not 
recommended in the most recent AUA Guidelines regarding treatment of benign prostatic hyperplasia (BPH). 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of iTind urology procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve iTind urology procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zilretta injection. 
 
You asked the Plan to pre-approve a Zilretta injection. You say that the requested Zilretta injection is medically 
necessary. The Plan denied your request. The Plan says the requested Zilretta injection 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 a Zilretta injection. Our reviewer says 
that the requested Zilretta injection is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The requested drug is being used for its 
current Food and Drug labelled indication. The Food and Drug Administration has not restricted its use to a 
single time. However, the medical necessity of the requested service is not supported by the documentation 
submitted. The record indicates that the enrollee received an injection of the requested drug in March 2022. 
There are no subsequent records that document the efficacy of the injection or the need for retreatment at this 
time. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 Zilretta injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Zilretta injection.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for emergency department 
services provided on December 15, 2021. 
 
You asked the Plan to reimburse you an additional amount for emergency department services. You say that 
you were not reimbursed the correct amount. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 clearly says that you must pay a $100 
copayment for Emergency Care.  
 
 
 
 
 
 You have been asked to pay a $100 copayment for emergency department services. Emergency department 
services falls within the Emergency Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reimburse you an 
additional amount for emergency department services provided on December 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99601 billed for date of service 
March 15, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99601. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
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 codes 99601 and 99601 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and 99601 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99601 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99601 billed for 
date of service March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a gym membership purchased on April 
14, 2022. 
 
You asked the Plan to pay an additional amount for a gym membership. You say that you want the Plan to pay 
an additional amount. The Plan denied your request. The Plan says they reimbursed the eligible amount of 
$99.54 (April-December of 2022, 9 months x $11.06). The remaining amount of $50.46 was not eligible for 
reimbursement under the current year's benefit because this amount applied towards the months in 2023. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility 
during the calendar year. 
 
The Plans rules for coverage of gym benefits have not been met because the remaining amount of $50.46 was 
not eligible for reimbursement under the current year's benefit. Therefore, we decided that the Plan does not 
have to pay an additional amount for a gym membership purchased on April 14, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and multiple procedures including 
angioplasty, atherectomy or stents. 
 You asked the Plan to pre-approve a consultation and multiple procedures including angioplasty, atherectomy 
or stents. 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 PTA of the carotid artery is covered when specific 
criteria are 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 consultation and multiple procedures 
including angioplasty, atherectomy or stents. Our reviewer says that the services are not medically necessary. 
Our physician reviewer found the provided documentation did not clearly reveal abnormal ankle brachial index 
(ABI) or abnormal ultrasound findings suggesting stenosis significant to warrant the proposed procedures. 
Also, there was no report this enrollee had tried and failed lifestyle and medical treatment strategies enough to 
justify these more invasive procedures for the enrollee's symptoms. The enrollee appears to have multiple 
reasons she has difficulty walking including dorsalgia, shortness of breath, and deconditioning. There was no 
skin breakdown or ulcer to support this request. Therefore, the documentation does not show sufficient support 
of the enrollee meeting criteria detailed in the NCD for the above services. 
 
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 consultation and multiple procedures including angioplasty, atherectomy or 
stents have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation and 
multiple procedures including angioplasty, atherectomy or stents.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT code G0482 is not supported in the medical record. Specifically, the records did not include 
results for the test at issue. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) 
provided February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatrist visit provided on April 19, 
2022. 
 
You asked the Plan to waive the copayment for a podiatrist visit. You say that all the doctor did was remove 
one sock and shoe, made a comment on your nails, then left. You say that no medical care was provided, and 
you feel this is fraud. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 clearly says that you must pay a $20 
copayment for per visit for Medicare-covered routine care.  
 
You have been asked to pay a $20 copayment for a podiatrist visit. A podiatrist office visit falls within the 
Podiatry Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a podiatrist visit 
provided on April 19, 2022. 
 Your complaint that medical care was not provided, and your concern of fraud, is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol tartrate. 
 
You asked the Plan to pre-approve Arformoterol tartrate. You say that the requested Arformoterol tartrate is 
medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Perforomist 
first. 
 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 Arformoterol tartrate. Our reviewer 
says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates 
that the enrollee has chronic obstructive pulmonary disease. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arformoterol tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol tartrate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on March 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99223 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the billing and rendering 
providers do not match. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care rendered on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (81455) 
provided on December 27, 2021. 
 
You asked the Plan to pay for a targeted genomic sequence analysis panel. You say that this was medically 
necessary. The Plan denied your request. The Plan says this is not supported in the records. 
 
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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
 
 
 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 a targeted genomic sequence analysis panel. Our reviewer 
says that the billed code is not supported. Our reviewer found a diagnosis of cancer was not provided to support 
laboratory service billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (81455) provided on 
December 27, 2021.