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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2022, billed with code 
87481 (two units). 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 a 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 
June 2, 2022, billed with code 87481 (two units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed place of 
service is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
documentation submitted by the non-contract provider did not contain medical records. As such, it cannot be determined if Medicare rules have been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and have 
submitted supporting clinical evidence for review. The Plan denied your request. The Plan says the request for 
a home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with an acute myocardial infarction. There is a listed diagnosis of COPD, but there is minimal smoking history 
and there are no pulmonary function tests. The enrollee has severe obesity and obstructive sleep apnea. ABG 
was consistent with acute on chronic hypercarbic respiratory failure.  The enrollee improved on BiPAP. A 
hospital progress note indicates that obesity hypoventilation syndrome is the proximate cause of the 
hypercarbic respiratory failure. This enrollee may benefit from BiPAP during sleep as an outpatient. If the 
enrollee has severe COPD, the AVAPS mode can be provided with BiPAP. Medicare does not cover a home 
ventilator for the diagnosis of obesity hypoventilation syndrome, or when used at settings that can be provided 
with BiPAP. 
 
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 (E0466).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the assistant at surgery services for procedure code 27447 provided on 
February 1, 2022. 
 
You asked the Plan to pay for procedure code 27447. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 
2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be 
paid. In this case, you billed assistant surgery services for CPT code 27447. The Medicare Fee Schedule 
Database contains a surgical indicator of 2 for this procedure. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27447 have been met. Therefore, we decided that the Plan has 
to pay for the assistant at surgery services for procedure code 27447 provided on February 1, 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 pre-approve Hyaluronan or derivitive, genvisc 850, for intra-articular 
injection, 1 mg (J7320). 
 
You asked the Plan to pre-approve an injection. You say that you were diagnosed with osteoarthritis of knee 
and need this service. The Plan denied your request. The Plan says you do not meet step therapy requirement. 
You are symptomatic. The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no indication that you have tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia, there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg (J7320).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home skilled nursing visits from March 
1, 2023, through April 21, 2023. 
 
You asked the Plan to pre-approve four additional home health service visits. You say that it is medically 
necessary for the enrollee to have the additional four home skilled nursing visits. The Plan denied your request. 
The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found no medical 
notes provided by the enrollee's treating physician documenting an order or need for additional skilled nursing 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home skilled nursing visits from March 1, 2023, through April 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that the requested services are medically 
necessary for the enrollee due to her diagnosis of both anal and breast cancer. Her disability will most certainly 
increase, and she will need increased care at home. The Plan denied your request. The Plan says they will cover 
hours requested for coverage via Medicaid guidelines. The Plan also say regarding the enrollee's Medicare 
benefit in this combined Medicare/Medicaid plan, Medicare does not cover custodial care or personal care 
attendant service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services, per 15 minutes (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) and accessories. 
 
You asked the Plan to pre-approve a group two PWC and accessories. You say that the enrollee needs a better 
wheelchair than what is being provided by the facility. The Plan denied your request. The Plan says the 
requested PWC is not covered because it will be used at a long-term care facility. 
 
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 a group two PWC and accessories is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve a group 2 power wheelchair (PWC) and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the records provided support the need for the 
injection services in dispute. The Plan denied your request. The Plan says there are no x-ray results in the 
doctor notes. The Plan says that they do not know if the enrollee failed to respond to 3-months of conservative 
therapy with either drugs or therapy. The Plan says that there is mention of knee pain but no mention of how 
this knee pain is affecting the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that for Medicare to consider 
coverage and payment for any item or service, the information submitted by the supplier or provider must 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met. Medicare rules also say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the 
clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee and when the patient has 
failed at least three months of conservative 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 Gelsyn-3. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no imaging or imaging 
impression included with the documentation. The progress notes state x-rays were taken, but there is no 
discussion of the results or when they were taken. It is also unclear how long conservative treatment (physical 
therapy) has been tried. The records state the pain has been present only for a couple of months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
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 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a new patient outpatient 
visit. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a new patient outpatient visit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev. 
 
You asked the Plan to pre-approve Ofev. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ofev.  
 
Benefits for Ofev 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition, endoskeletal system, above knee or hip disarticulation, knee extension 
assist (L5850), an all lower extremity prostheses, flex-walk system or equal (L5981), and an all endoskeletal 
lower extremity prosthesis, axial rotation unit, with or without adjustability (L5984). 
 
You asked the Plan to pre-approve prosthetics. You say that this request is not for an advanced foot/knee 
feature. It is a replacement of components which the enrollee previously had. Without his prosthesis 
functioning properly, he is unable to ambulate. You have attached supporting documentation and a certificate 
of medical necessity. The Plan denied your request. The Plan says the requested prosthetics exceed the 
enrollee's need and cannot be 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the flex-walk system L5981 and the L5828, L5845, L5850, exceed the enrollee's medical needs 
and is not medically necessary per LCA A52496, Local Coverage Determination (LCD): Lower Limb 
Prostheses (L33787) and per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). The 
treating medical physician provider documentation does not support that the enrollee is a K3 ambulator. 
Furthermore, the physician documentation does not reveal that the enrollee requires the L5984 axial rotation 
unit which must be used with the base foot per A52496. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), an all lower 
extremity prostheses, flex-walk system or equal (L5981), and an all endoskeletal lower extremity prosthesis, 
axial rotation unit, with or without adjustability (L5984).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. 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. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray of the left foot billed with procedure code 73630, provided on 
September 27, 2022. 
 
You asked the Plan to pay for the  x-ray of the left foot. You say that the correct modifier was used. The Plan 
denied your request. The Plan says that the procedure code is missing the appropriate anatomical modifier. 
 
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 denied due to missing modifiers to identify the toes that were imaged. The x-ray was for the whole 
foot, so modifiers for specific toes would not be appropriate for this service. As there was no alternate rationale 
presented by the Plan, we find that the denial of payment for these services is not supported 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the diagnosis is consistent with the procedure billed. Therefore, we decided that 
the Plan has to pay for the x-ray of the left foot billed with procedure code 73630, provided on September 27, 
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 pay for injection services (procedure code J7999) rendered on March 
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 there is a more appropriate code to use. 
 
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 J7999 is "Compounded drug, not otherwise classified." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to validate that a compounded drug was administered. The denied 
code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 injection services (procedure code J7999) rendered on March 16, 2022.