Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the group 3 power wheelchair with multiple power options and 
upgraded electronics. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the request was denied for Medicare 
criteria not met and you feel that this is incorrect, and that the information was overlooked. Please reconsider 
the prior authorization for approval. The Plan denied your request. The Plan says that the enrollee meets the 
criteria for a group 3 power wheelchair with no power options. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 power wheelchair. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires the requested group 3 power wheelchair with the multiple power 
options, including the power tilt and recline and power elevating leg rest, and the necessary expandable controller and connectors. She requires the power tilt and recline given the fact that she has weakness and 
spasticity which impairs her ability to perform adequate pressure relief. Therefore, she is at risk for skin 
breakdown, especially given the fact that she is incontinent of bowel and bladder. Power tilt by itself would not 
provide appropriate pressure relief given the complexity of her seating needs due to her weakness and 
spasticity. She also requires power tilt and recline for bladder management. The enrollee requires a power 
elevating right leg rest given her lower extremity spasticity and positioning and pressure relief needs. She 
requires a custom seating system for the power wheelchair due to the fact that she has pelvic asymmetry and 
scoliosis, and standard cushions will not accommodate for her postural asymmetry. The requested group 3 
power wheelchair and its requested components are 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 power wheelchair have been met. Therefore, we decided that the Plan has to 
pre-approve the group 3 power wheelchair with multiple power options and upgraded electronics.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing provided on February 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case include the test order and the test results and a letter from the 
vendor/manufacturer arguing medical necessity of the test, but the records do not include any documentation from the enrollee's treating provider explaining the necessity of the test and how the results will assist in 
management of 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant Reveal testing provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, a procedure that uses 
heat from the tip of an electrical probe that vibrates to destroy a nerve in the neck or mid back for pain relief 
(CPT code 64633) and destruction by neurolytic agent, a procedure that uses heat from the tip of an electrical 
probe that vibrates to destroy a nerve in the neck or mid back for pain relief (CPT code 64634). 
 
You asked the Plan to pre-approve the services. You say that the enrollee complains of continued neck pain, 
left shoulder pain which limits the enrollee's daily activities. You state the enrollee notes decreased range of 
motion in the left shoulder and they have difficulty with overhead activities and reaching behind the enrollee. 
The Plan denied your request. The Plan says the requested procedure is supported if the enrollee's pain is 
localized to either the enrollee's neck or back and does not travel to other areas of their body. The Plan states 
the enrollee's records do not show that the enrollee has this type of pain. 
 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 physician reviewer 
found there are no diagnostic medial branch blocks (MBBs) documented. Radiofrequency ablation (RFA) is 
not indicated at this time. The request is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, a procedure that uses heat from the tip of an electrical 
probe that vibrates to destroy a nerve in the neck or mid back for pain relief (CPT code 64633) and destruction 
by neurolytic agent, a procedure that uses heat from the tip of an electrical probe that vibrates to destroy a 
nerve in the neck or mid back for pain relief (CPT code 64634).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary for treatment of 
the enrollee's iron deficiency anemia. The Plan denied your request. The Plan says the enrollee has not tried 
and failed the preferred step therapy drugs. 
 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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Infed 
and Venofer before they will approve the requested drug. The enrollee has not tried and failed the required 
drugs. There is no evidence that the Plan's required drugs would likely be less effective and/or likely have an 
adverse effect 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their 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 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 December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance (E0673) 
provided to the enrollee on December 13, 2021. 
 
You asked the Plan to pay for the item. You say that this was provided and then removed before discharge. The 
Plan denied your request. The Plan says since the place of service is an ambulatory surgical center, this device 
is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that E0673 is not covered without the base device. 
 
E0673 cannot be covered without the approved related base device, such as E0675. Based on this information, 
we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan 
does not have to pay for a segmental gradient pressure pneumatic appliance (E0673) provided to the enrollee 
on December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional x-ray services provided to the enrollee on July 3, 
2021. 
 
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 the records submitted do not indicate that two separate services were performed or 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 73030 is "Radiologic examination, shoulder; complete, 
minimum of 2 views." 
 
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 records show a single exam of 
the left shoulder, minimum of two views (CPT 73030) for July 3, 2021, and was reported and signed by the 
doctor at 00:41. 
 
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 additional x-ray services provided to the enrollee on July 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83695, 83550, 83540, 80053) provided on 
March 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the service was not emergent. There were network providers available. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. 
 The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for lab services (83695, 83550, 83540, 
80053) provided on March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for intravenous (IV) therapy on February 16, 
2022, to February 28, 2022. 
 
You asked the Plan to waive the copayments for IV therapy. You say that you feel it would have been less 
money if he stayed inpatient instead of going 5 minutes each infusion and now have to pay so much for 
outpatient hospital. The Plan denied your request. The Plan says the cost-sharing you are being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic. We cover 
medically necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an 
illness or injury. Covered services include but are not limited to: Certain drugs and biologicals that you cant 
give yourself. The approved amount is $239.17, which is less than the copayment amount. There were 12 total 
visits, resulting in a total copayment amount of $2,870.04. 
  The enrollee has been asked to pay a $239.17 copayment, which is less than the copayment for each IV 
therapy. IV therapy falls within the Outpatient hospital services benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for intravenous (IV) therapy on February 16, 2022, to February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
January 9, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment was medically necessary based on 
the enrollee's medical condition. The Plan denied your request. The Plan says the enrollee had no cardiac 
issues. 
 
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 records show that the enrollee requested testing to determine whether she is affected or known for having a 
gene mutation. Asymptomatic testing is not covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for the hereditary cardiovascular screening panel provided on January 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy (interlaminar 
approach) 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 enrollee is not in a clinical study nor a longitudinal study. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that percutaneous laminotomy remains experimental. Open surgery is the gold standard. More research is 
needed to show that percutaneous surgery is safe and effective. 
 
 
 
 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 a percutaneous laminotomy/laminectomy (interlaminar approach) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) for sacroiliac joint pain 
(64625) provided on January 26, 2022. 
 
You asked the Plan to pay for the RFA for sacroiliac joint pain. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. Based on this information, we decided that Medicare rules for coverage of the RFA for 
sacroiliac joint pain have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiofrequency ablation (RFA) for sacroiliac joint pain (64625) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sclerotherapy treatment (CPT code 36471). 
 
You asked the Plan to pre-approve the service. You say that you had the procedure done in December 2012 and 
you felt like a different person. You state you had an ultrasound on your leg in March 2022 and the results 
indicated that your veins are back in a different area than before. The Plan denied your request. The Plan says 
the Medicare rules have not been 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 the service. Our physician reviewer 
found the documentation does not support that you are considered symptomatic, based on the rules. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral sclerotherapy treatment (CPT code 36471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine foot care (11056, 10057). 
 
You asked the Plan to pre-approve the routine foot care. You say that this service is medically necessary. The 
Plan denied your request. The Plan says insufficient information is available to determine if the requested codes 
are medically necessary. 
 
The Plan must follow Medicare rules. 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. 
 
 
 
 
 
 
 
 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 routine foot care (11056, 10057). have 
been met. The information available does not show how many additional corns will need treatment. The plan 
has approved initial evaluation and treatment. Therefore, we decided that the Plan does not have to pre-approve 
routine foot care (11056, 10057).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network tertiary level referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are multiple in-network providers available. 
 
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 tertiary level referral.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. The Plan denied your request. The Plan says 
this is 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 Vertiflex Superion device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Vertiflex spacer is experimental, and 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 11, 2022.