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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not have a detailed history that shows this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the services. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
cirrhosis and is thus at risk for hepatocellular carcinoma. The written order is for MRI of the abdomen without 
and with contrast which would correspond to Current Procedural Terminology (CPT 74183, and would be 
approved if the request was properly coded. There is no support in the submitted records for MRI of the 
cervical spine - CPT 72156 or 72141. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 You asked the Plan to pre-approve the Orthovisc. You say that you would like reconsideration because the 
Orthovisc is medically necessary. The Plan denied your request. The Plan says you do not meet step therapy 
exception 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 the Orthovisc. Our reviewer says that 
hte Plan requires a trial of drug Euflexxa before they will approve the requested drug. The case file does not 
contain documentation of trail and failure of Euflexxa. Our physician reviewer found the documentation does 
not support that Euflexxa would likely be less effective, and/or would likely have adverse effects. 
 
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 Orthovisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode that could be delivered by bilateral positive airway pressure (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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has moderate to severe chronic obstructive pulmonary disease (COPD) with a recent exacerbation that did not 
require hospitalization.  There is no arterial blood gas (ABG) study showing C02 retention. If the enrollee is retaining C02 chronically, 
he may benefit from bilateral positive airway pressure (BiPAP) during sleep, with AVAPS mode and backup 
rate. This has not been tried. Medicare does not cover a home ventilator when used as BiPAP. The enrollee 
does not need continuous ventilator support. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services rendered on June 24, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
 
 
 
 
  
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the infusion services rendered on June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq 25mg tablets. 
 
You asked the Plan to pre-approve Myrbetriq. You say that Myrbetriq is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Myrbetriq 25mg tablets.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry testing (83789) provided on November 2, 
2021. 
 
You asked the Plan to pay for mass spectrometry. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 83789 is 
included in code G0480 and is not separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this testing was a separate and distinct procedure from the 
covered drug testing code G0480.  
 Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for mass spectrometry testing 
(83789) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are payable by Medicare. 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 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 May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous transcatheter placement of intracoronary 
stent (92929) provided on May 5, 2021. 
 
You asked the Plan to pay for the transcatheter placement. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says payment for this service is 
included in another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 92929 is percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary 
artery (List separately in addition to code for primary procedure). 
 
We looked at the file and Medicare rules. In this case, code 92929 has a Status Code of "B" under the 
Physician Fee Schedule. This means that payment for covered services are always bundled into payment for 
other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
transcatheter placement have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous transcatheter placement of intracoronary stent (92929) provided on May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) is still 
considered investigational and therefore 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is experimental. More research is 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ultrasound scan rendered on October 4, 
2021. 
 
You asked the Plan to waive the deductible for the ultrasound scan. You say that you thought you would be 
covered in full. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare-covered diagnostic radiology, after you meet your $1,000 deductible. At the 
times this claim was processed, $712.84 of the $1000 deductible had been met. The allowed amount of this 
claim is $248.83, resulting in a deductible amount of $248.83 because this does not yet meet the $1000 
deductible for 2021. You have been asked to pay $248.83, which is 20% coinsurance for the ultrasound scan. The ultrasound scan 
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 deductible for the ultrasound scan rendered on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2020. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, the enrollee does not meet all of the required criteria 
for this admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not meet the criteria for this admission. There are no new medical problems. The enrollee is medically stable, and does not need physician close supervision 3 times per week (at 
a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no acute rehab nursing needs identified or documented in the record. The enrollee does not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. She did not improve with daily therapies for a month in 
the skilled nursing facility (SNF). At the current level of function, the enrollee's rehabilitation can be safely 
provided at a lower intensity and alternate setting such as in an assisted living facility with care and intermittent 
therapies as 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 14, 
2020. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 the drug testing services (G0483) provided on December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orthofix Trinity Elite allograft. 
 
You asked the Plan to pre-approve an Orthofix Trinity Elite allograft. You say that this service is medically 
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this 
service. 
 
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 Orthofix Trinity Elite allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that Orthofix Trinity Elite allograft is experimental in spine surgery. More 
research is needed to show safety and efficacy.

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 Orthofix Trinity Elite allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an Orthofix Trinity Elite allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are payable by Medicare. 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 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 May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310) for the enrollee. 
 
You asked the Plan to pre-approve the connection. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has adequate upper limb strength and function to be able to control the 
power options using their own switches which are included in the allowance of this power options. 
 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 connection. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has one power option of power elevating leg rests on the approved wheelchair. The 
enrollee's upper extremity strength and function support that the enrollee can control any power options 
through their own switches. 
 
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 connection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2310) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services rendered on August 10, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the infusion services rendered on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services (88305) provided on June 30, 
2021. 
 
You asked the Plan to pay for surgical pathology services. You say that this was billed correctly. The Plan 
denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The records indicate that the enrollee was a hospital patient at the 
time of service, and this service was not billed with a modifier to indicate only the professional component is 
being billed. Based on this information, we decided that Medicare rules for coverage of surgical pathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology 
services (88305) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 16, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 16, 2021.