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

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
(63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of a neurostimulator. 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 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 percutaneous implantation of a 
neurostimulator. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial 
and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Documentation 
does not support a trial and failure of any injection therapy or any therapy trial and failure outside of physical 
therapy (chiropractic treatment, acupuncture, massage, etc.). The lack of failure of all less invasive 
conservative procedures does not support this request as a late or last resort. 
 
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 percutaneous implantation of a neurostimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
(63650).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan of the prostate. 
 
You asked the Plan to pre-approve a PET scan of the prostate. You say that a PET scan is medically necessary. 
The Plan denied your request. The Plan says that a PET scan does not meet the Plan's medical technology 
assessment criteria or the Plan's Medical Policy guidelines for the procedure reported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan of the prostate. Our 
reviewer says that a PET scan is medically reasonable and necessary. Our physician reviewer found the 
PET/CT using Prostate Specific Membrane Antigen (PSMA) technique is a single test which will determine if 
all of the abnormal findings on CT are related to a prostate primary tumor. This is important since there is a 
possibility that the thoracic disease is related to a non-prostate primary tumor. The use of a prostate specific 
PET agent will allow this determination and allow for appropriate anti-tumor therapy. 
 
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 PET scan of the prostate. have been met. Therefore, we decided that the Plan 
has to pre-approve a PET scan of the prostate.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig purchased on August 15, 2021. 
 
You asked the Plan to pay for these services. You say that the plan paid in full for your previous hairpiece. The 
Plan denied your request. The Plan says the services are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig purchased on 
August 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
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 pay for a fluid circulating cold pad with pump (E0218).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the tests are performed in your facility. The Plan 
denied your request. The Plan says the code remains not supported. 
 
 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. The claim at issue was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 the lab services provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency joint denervation/ablation. 
 
You asked the Plan to pre-approve radiofrequency joint denervation/ablation. You say that radiofrequency joint 
denervation/ablation is medically necessary. The Plan denied your request. The Plan says radiofrequency 
ablation for joint pain is considered experimental or investigational. 
 
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 radiofrequency joint 
denervation/ablation. Our reviewer says that the requested radiofrequency joint denervation/ablation is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that this procedure is 
considered experimental/ investigational. It is the subject of ongoing clinical trials and its role in the treatment 
of knee osteoarthritis is still being evaluated.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency joint denervation/ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency joint denervation/ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on October 1, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on October 1, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the knee brace is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage for codes L1832, L1833, L1843, L1845, 
L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and there 
must be an objective description of joint laxity. 
 
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 knee orthosis. Our reviewer says 
that the brace is not medically necessary. Our physician reviewer found the documentation does not reveal 
evidence of objective instability or pathologic laxity on the knee physical examination. There is no evidence of 
a recent surgery or injury to the knee. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1852).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for these services the computed tomography 
(CT), abdomen and pelvis, without contrast material (74176), electrocardiogram, routine 12+ leads; tracing 
only w/o interpretation and report (93005), cystourethroscopy and/or pyeloscopy; with lithotripsy including 
insertion of indwelling ureteral stent (eg, gibbons or double -J type) (52356LT) and self-administered drugs 
(A9270GY), rendered on August 17, 2021, to September 14, 2021. 
 You asked the Plan to waive the copayment for these services . You say that the services should be covered. 
The Plan denied your request. The Plan says the cost share was applied 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 
$250.00 co-payment for covered diagnostic radiology services in the outpatient department of a network 
hospital of facility and a $285.00 co-payment for each covered surgery or observation room service in an 
outpatient hospital. 
 
You have been asked to pay a $250.00 co-payment for covered diagnostic radiology services in the outpatient 
department of a network hospital of facility and  a $285.00 co-payment for each covered surgery or observation 
room service in an outpatient hospital. These services fall within the outpatient diagnostic tests and therapeutic 
services and supplies and Outpatient hospital observation benefit categories. The self-administered drug is not a 
covered benefit. 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 these services the computed 
tomography (CT), abdomen and pelvis, without contrast material (74176), electrocardiogram, routine 12+ 
leads; tracing only w/o interpretation and report (93005), cystourethroscopy and/or pyeloscopy; with lithotripsy 
including insertion of indwelling ureteral stent (eg, gibbons or double -J type) (52356LT) and self-administered 
drugs (A9270GY), rendered on August 17, 2021, to September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 13, 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 procedure codes 52352 and 52353 are 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 52352 is cystourethroscopy, with ureteroscopy and/or 
pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included). The definition of 
code 52353 is cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral 
catheterization is included). 
 
 We find that CPT codes 52352 and 52353 are not supported in the medical record. Specifically, the operative 
report does not include documentation of a cystourethroscpy with ureteroscopy and/or pyeloscopy, with 
removal or manipulation of calculus to support code 52352. There is no documentation of a cystourethroscopy 
with ureteroscopy and/or pyeloscopy, with lithotripsy to support code 52353. 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 surgical services rendered on May 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-rays provided on August 24, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 8, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit and 
x-rays provided on August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spine x-ray (72100), hip x-ray (73502), outpatient 
hospital clinic visit (G0463), and Ketorolac Tromethamine injection (J1885) provided on November 10, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the spine x-ray, hip x-ray, outpatient hospital clinic visit, and Ketorolac 
Tromethamine injection. You say that you believe these services should be reconsidered for coverage. The Plan 
denied your request. The Plan says the treating provider is not a network provider with the Plan. The Plan also 
says that that these services are not urgent or emergent, nor were they approved in advance. 
 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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the spine x-ray (72100), hip x-ray (73502), 
outpatient hospital clinic visit (G0463), and Ketorolac Tromethamine injection (J1885) provided on November 
10, 2021 by an out-of-network (OON) provider.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee has recovered well post-operation. 
 
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 there is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BRCA1 and BRCA2 genetic testing. 
 
You asked the Plan to pre-approve the BRCA1 and BRCA2 genetic testing. You say that the requested BRCA1 
and BRCA2 genetic testing is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested BRCA1 and BRCA2 genetic testing. 
 
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 BRCA1 and BRCA2 genetic 
testing. Our reviewer says that the enrollee does not meet criteria for the requested BRCA1 and BRCA2 
genetic testing. Our physician reviewer found the enrollee does not meet the LCD criteria for genetic testing for 
BRCA1 and BRCA2. She is over the age of 50 with a lobular hormone positive breast cancer and family 
history does not fit any of the coverage criteria. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the BRCA1 and BRCA2 genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the BRCA1 and BRCA2 genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 28, 2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on September 28, 2021.
Appeal type: Step-Therapy
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 the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron dextran) 
and Venofer (iron sucrose). 
 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 the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the required drugs. There is no documentation provided indicating 
that the plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel provided on September 27, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the results allow the physician to make 
treatment decisions. The Plan denied your request. The Plan says the procedure code billed is not correct. 
 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. The gene panel at issue was billed with multiple codes. If a single 
procedure is performed, only one 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 pharmacogenomics panel provided on 
September 27, 2021.