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

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on October 4, 2021. 
 
You asked the Plan to pay for hearing aids. You say that you need hearing aids, and this provider had the best 
price options. The Plan denied your request. The Plan says hearing aids are only covered when they are 
purchased through the Plan's specified routine hearing vendor network. You are responsible for all costs for 
hearing aids not purchased through this vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the specified hearing vendor network.  
 
 
 
  
 
We looked the file and the Plan's rules. The provider in this case is not part of the Plans routine hearing vendor 
network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) provided on 
October 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry interpretation (88189) provided on 
September 3, 2021. 
 
You asked the Plan to pay for flow cytometry interpretation. You say that this service was billed correctly and 
does not conflict with the other services billed. The Plan denied your request. The Plan says that it is 
inappropriate to bill code 88189 with modifier 26 because this code describes only the professional component 
without a modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the CPT code 88189 has a professional/technical indicator of 2. This means this is a standalone code that 
describes the physician work portion of selected diagnostic tests for which there is an associated code that 
describes the technical component of the diagnostic test only and another associated code that describes the 
global test. Modifiers 26 and TC cannot be used with these codes. 
 
We find that CPT code 88189 is not supported in the medical record. Specifically, this code was billed with 
modifier 26. Based on this information, we decided that Medicare rules for coverage of flow cytometry 
interpretation have not been met. Therefore, we decided that the Plan does not have to pay for flow cytometry 
interpretation (88189) provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx: Targeted genomic sequence analysis, 
solid organ neoplasm, DNA analysis of 324 genes, (0037U) provided June 23, 2021. 
 
You asked the Plan to pay for FoundationOne CDx test. You say that the provision of this test meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the benefit for this service has 
been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Medicare rules says that this testing is a covered benefit, once in a 
lifetime per cancer diagnosis. The records show that genetic testing for pancreatic cancer was completed June 14, 2021. Therefore, the benefit is exhausted. Based on this information, we decided that Medicare rules for 
coverage of FoundationOne CDx test have not been met. Therefore, we decided that the Plan does not have to 
pay for FoundationOne CDx: Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 
genes, (0037U) provided June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen handling (99000) provided on October 29, 
2021. 
 
You asked the Plan to pay for the specimen handling (99000). You say that the claim should be reopened and 
reviewed. The Plan denied your request. The Plan says bundled services are not eligible for separate payment. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the specimen handling (99000) have not been met. Therefore, we decided that the Plan does not have to pay 
for the specimen handling (99000) provided on October 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the requested 
Vertiflex device is considered to be experimental. More research is needed. The requested Vertiflex device is 
not medically necessary at this time. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve SNF admission. You say that if the enrollee goes home, she will not get the 
care that she needs. The Plan denied your request. The Plan says the enrollee's current level of function does 
not require the services of skilled nursing, and while you would benefit from further therapy, this could be 
provided safely at a lessor level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our physician reviewer 
found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF admission.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee has not failed two antidepressants. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Spravato. Our reviewer says that the 
requested use of Spravato is supported in this case. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of treatment resistant major depression and that the requested drug will be taken with 
an oral anti-depressant. The Food and Drug Administration has stated that the requested drug is indicated for 
the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spravato have been met. Therefore, we decided that the Plan has to pre-approve 
Spravato.  
 
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: 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 these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this 
is an appropriate procedure for the enrollee's back pain. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. The non-radiating midline back pain along with the 
diminished and painful spinal motion (in all directions) and intact neurologic exam are all non-specific to any 
pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric for the enrollee. 
 
You asked the Plan to pre-approve Monoferric. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs) would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Monoferric. Our reviewer says that 
Monoferric is not medically reasonable and necessary. The Plan requires a trial of Infed (iron dextran) and 
Venofer (iron sucrose) before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Monoferric. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had on October 18, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the benefit limit has been 
exceeded. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided on August 18, 2021, which is less than 12 months prior to 
the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness 
visit you had on October 18, 2021.
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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Arformoterol Tartrate for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this drug is subject to step therapy 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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found step therapy may only be 
applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the 
affected medication. In this case, the clinical documentation supports that the enrollee was actively receiving 
Arformoterol in the hospital in May, 2022, and Arformoterol is on the Medication List at Discharge as of 
5/13/2022. The drug is medically reasonable and necessary for the enrollee in this case. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Arformoterol Tartrate for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have one of the covered indications. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test in the 
evaluation of dizziness without chest pain. The electrocardiogram and echocardiogram are unremarkable. There 
is no evidence provided that would support the need for radionuclide stress testing in this enrollee's clinical 
management. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power options (K0862). 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair. You say that the requested item is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested item have not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or  
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 heavy duty power wheelchair with multiple power options (K0862).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 You asked the Plan to pre-approve the requested services. You say that you are in extreme pain. The Plan 
denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that you have chronic axial neck pain. You have had a series of left C3-C6 medial branch 
blocks (MBBs), which have provided you with 75% pain relief. The request is for another MBB. This request 
does not meet coverage criteria regarding percentage of pain relief and the use of radiofrequency ablation after 
2 positive MBBs. Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles and Tdap vaccines you received on December 9, 
2021. 
 
You asked the Plan to pay for the vaccines. You say that you were not told the vaccines wouldn't be covered. 
The Plan denied your request. The Plan says these vaccines are not covered under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccines. 
Therefore, we decided that the Plan does not have to pay for the shingles and Tdap vaccines you received on 
December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are requesting an appeal 
regarding the denial of coverage for the Flexitouch pneumatic compression pump prescribed. The Plan denied 
your request. The Plan says the enrollee does not meet the LCD criteria as the records do not document that 
there is edema extending over to the trunk. A PCD coded as E0652 is not covered for the treatment of 
lymphedema of the extremities alone 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. A PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone even if the criteria in this section are met.  Claims will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the records provided do not document that there is edema 
extending over to the trunk. A PCD coded as E0652 is not covered for the treatment of lymphedema of the 
extremities alone even if the criteria in this section are met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652).