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

 
We decided that the Plan does not have to pre-approve MLH1 gene testing. 
 
You asked the Plan to pre-approve genetic testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says MLH1 testing is non-covered per policy criteria, as this test is never 
considered to have clinical utility for any indication. 
 
The Plan must follow Medicare rules. Medicare rules say that individual testing for the MLH1 gene is unlikely 
to impact therapeutic decision making, directly impact treatment, outcome and/or clinical management in the 
care of the beneficiary and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. The requested test in this case is for only the MLH1 gene. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve MLH1 gene testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on July 24, 2019. 
 
You asked the Plan to pay for the ultrasound. You say that this should be paid. The Plan denied your request. 
The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ultrasound was not filed until April 21, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the abdominal ultrasound (76700) provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp, supra pole, bathroom security pole, 
and easy grip reacher. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the items 
are not used for a primary medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items do not serve a purpose that is primarily medical in nature. The items are 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 pre-approve a wheelchair ramp, supra pole, bathroom security pole, and easy grip reacher.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Aranesp. Our physician reviewer found the file does not 
contain documentation of trial and failure of the Plan's preferred drugs, Retacrit or Procrit. Our reviewer also 
found that the documentation does not support that Retacrit, or Procrit would likely be less effective, and/or 
would likely have adverse effects 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fetal echocardiography services (76825, 76827, 93325) 
provided on March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for fetal echocardiography services. You say that you want the Plan to pay for the 
services. The Plan denied your request. The Plan says the provider is out-of-network, and the services were not 
authorized 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 fetal echocardiography services (76825, 76827, 
93325) provided on March 23, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on May 26, 
2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on May 26, 2022.  
 Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute, lower leg platform, with or 
without wheels (E0118). 
 
You asked the Plan to pre-approve the knee scooter. You say that you believe that it is medically necessary to 
have a knee walker for achieving mobility around your home. Your home is split level and not wheelchair 
accessible. The Plan denied your request. The Plan says Medicare criteria for walking equipment does not 
cover this type of crutch. There is insufficient published clinical literature demonstrating safety and 
effectiveness in the Medicare population to establish the medical necessity for these products. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve the crutch substitute, lower leg platform, with 
or without wheels (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the device is needed due to 
poor circulation. The Plan denied your request. The Plan says this request does not meet Medicare 
requirements for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor supply allowance provided on April 16, 
2022. 
 
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that this claim 
will need to be submitted to the member's primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor supply allowance provided 
on April 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on October 27, 
2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you canceled the appointment but 
the doctors office called and spoke to you for 5 minutes. You say that you feel this claim should not have been 
filed because this was not a telehealth visit. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $40 
copayment for physician/practitioner service. 
 
 
 
 
 You have been asked to pay a $40 copayment for specialist visit. This item/service falls within the 
physician/practitioner service 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. The specialist visit was performed via telehealth. Therefore, we decided that the Plan does 
not have to waive the copayment for specialist visit provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2022 billed with 
codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, and 81479 
. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says if one laboratory procedure evaluates multiple genes using a next generation 
sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing 
procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary 
laboratory analysis CPT code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 2, 2022 billed with codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, and 
81479 
.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that a nurse came out to evaluate you and 
stated you were a fall risk. You say that you fall a lot and do not need to have critical occurrences. The Plan 
denied your request. The Plan says there is no evidence that the requested power wheelchair is medically 
necessary. The Plan says that the information does not show that it is not cost effective to repair the enrollee's 
current power wheelchair. 
 The Plan follows Medicare rules. Medicare rules say that replacement of a device is only covered for certain 
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 a power wheelchair. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the requested replacement 
power wheelchair is not medically necessary. The documentation does not support that there has been a change 
in the physiological condition of the patient. There is no evidence of an irreparable change in the condition of 
the device, or in a part of the device; or that the condition of the device, or the part of the device, requires 
repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or of the 
part being replaced. The documentation does not reveal that the patient is unable to perform mobility related 
activities of daily living (MRADLs) in the home with her current wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (CGM) 
provided to the enrollee from January 17, 2022, to February 17, 2022. 
 
You asked the Plan to pay for the allowance. You say that this should be reconsidered. The Plan denied your 
request. The Plan says there is a requirement that the treating practitioner has a face-to-face encounter with a 
beneficiary within the six months prior to prescribing items that appear on the Required List. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have had an 
in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment 
plan. Based on this information, we decided that Medicare rules for coverage of the allowance have not been 
met. Therefore, we decided that the Plan does not have to pay for a supply allowance for a continuous glucose 
monitor (CGM) provided to the enrollee from January 17, 2022, to February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 
You asked the Plan to pre-approve Epogen. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, Retacrit 
or Procrit, for at least two consecutive months. 
 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 Epogen. 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 preferred drugs. The reviewer found that there is no indication that the 
plan's required drug(s) 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 Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen (J0885).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 8, 2021, to 
November 12, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 194 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the enrollee presented to the hospital with 
fatigue and dizziness with body aches, fever and leukocytosis. However, there was insufficient objective 
evidence found in the provided documentation showing a dysregulated systemic response to infection. The 
enrollee was hemodynamically stable. Kidney, liver, and brain status was noted as stable. Sepsis 3 criteria was 
not met by this enrollee on this admission. Therefore, the records did not support sepsis as a diagnosis for this 
admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 8, 2021, to November 
12, 2021, as billed with Diagnosis Related Group (DRG) 871.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you strongly recommend an LTACH 
level of care for this enrollee. The Plan denied your request. The Plan says the criteria for admission to the 
LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not stable for transfer 
and as it would not be clinically advantageous at this time. Our physician reviewer also found that completion 
of treatment at the current facility is recommended. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.