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

 
We decided that the Plan does not have to pre-approve the F2 gene analysis (81240) and F5 gene analysis 
(81241). 
 
You asked the Plan to pre-approve the gene analysis services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says these services are not covered by Medicare for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested F5 and F2 gene analysis services 
are noncovered except for pregnant patients. Based on this information, we decided that Medicare rules for 
coverage of the gene analysis services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the F2 gene analysis (81240) and F5 gene analysis (81241).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress echocardiogram (93351). 
 
You asked the Plan to pre-approve a stress echocardiogram. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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 stress echocardiogram. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollees pre-test probability for an abnormal test is low and there is no 
documentation that the ECG shows an uninterpretable pattern. There is insufficient documentation to support 
the medical necessity for the requested stress echocardiography in this enrollees 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 a stress echocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a stress echocardiogram (93351).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says the requested Procrit is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit. Our reviewer says that the 
requested Procrit is not medically necessary. Our physician reviewer found Procrit is not Food and Drug 
Administration-approved for essential thrombocythemia and unspecified anemia. The use of Procrit for 
essential thrombocythemia and unspecified anemia is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 26, 2021. 
 
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 that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 26, 2021.  
 
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 pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve temozolomide (J8700). 
 
You asked the Plan to pre-approve temozolomide. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 temozolomide. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found this drug is not FDA approved for the 
members diagnosis and there are no major compendia supporting this drug in combination 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 temozolomide have not been met. Therefore, we decided that the Plan does not 
have to pre-approve temozolomide (J8700).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428) 
provided on July 11, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that these services are not covered by the 
Skilled Nursing Facility fees and should be paid separately. The Plan denied your request. The Plan says that 
this ambulance transport is covered by the skilled nursing facility (SNF) prospective payment system (PPS) and 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the documentation shows that the enrollee was inpatient at the SNF on the date in question and was 
brought to the hospital for additional care which is not available at the SNF and then returned to the SNF after 
care. This means that the transport services are included as part of the SNF PPS and are not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance 
transportation services (A0428) provided on July 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 4, 
2021. 
 
You asked the Plan to pay for the CT scan. You say that the medical records support the services. The Plan 
denied your request. The Plan says an appropriate modifier was not billed. 
 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, CPT code70450 was billed with CPT code 70496. We find that CPT code 70450 may be eligible 
for payment when billed with this code pair. The claim information does not show that the code at issue was 
billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan provided on June 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, 
A0425) provided on August 18, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that this transport was a non-emergency 
discharge from the hospital back to the facility after treatment for a severe infection. These services were 
necessary and are separately payable. The Plan denied your request. The Plan says that the enrollee was listed 
as inpatient at the facility on the date in question, and therefore the payment for these services is included in the 
facility fees. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that separate payment for these services is not supported in the record. Specifically, the enrollee is shown to 
have been inpatient status at the hospital from July 30, 2021, to August 19, 2021. This means that the 
transportation was provided while the enrollee was inpatient status at the hospital. This means that the transport is included in the payment to the facility. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to 
pay for the non-emergent ambulance transportation services (A0428, A0425) provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the clinical documentation provided does not show that the member has tried and failed 
a four-week trial of the basic pump including regular, daily, multiple-hour home usage of a PCD coded as 
E0650 or E0651. 
 
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 DME. Our physician reviewer 
found the provided documentation did not describe the patient having tried and failed a regular pump for their 
condition and there was no documentation of the patient having truncal lymphedema to justify this request. The 
records do not meet the LCD requirements for Medicare coverage. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code 
E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on October 2, 
2021. 
 
You asked the Plan to pay for critical care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the enrollee has another insurance carrier as their primary insurance. The 
Plan has attempted to reached out to this carrier, and has contacted the provider, as the Explanation of Benefits 
(EOB) from that Plan is necessary to proceed with processing this claim. At the time of this decision, the 
necessary documentation had not been received. The Plan states that once the primary insurance EOB is 
received, they will take necessary action. 
 
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 met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to 
contact the primary carrier directly and has contacted the provider to verify that the claim as sent to the primary 
insurer and that an EOB from this insurance provider is necessary to process this claim. As the secondary 
insurer, the Plan cannot be held responsible for critical care until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) 
provided on October 2, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the endoscopy procedure to be performed at a hospital setting. 
 
You asked the Plan to pre-approve the procedure to be performed at a hospital setting. You say that the 
physician does not have privileges at a contracted ambulatory surgical center. The Plan denied your request. 
The Plan says that the endoscopy can be done by GI with ambulatory surgical center privileges. 
 
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 procedure to be performed at a 
hospital setting. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the appellant is elderly, has multi-systemic disease, and 
meets the spirit of health plan sight of care criteria as provided. More to the point of this review, Appellant's 
requested site of care meets Medicare medical appropriateness and necessity criteria as follows: 
 Safe and effective; 
 Not mainly for the convenience of the patient or the physician; 
 Not experimental or investigational; and 
 Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of 
whether it is: 
   - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member; 
   - Furnished in a setting appropriate to the patient's medical needs and 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 the procedure to be performed at a hospital setting have been met. Therefore, 
we decided that the Plan has to pre-approve the endoscopy procedure to be performed at a hospital setting.  
 
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 pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a trial of use of a basic pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is reported to have lymphedema of the trunk, however, this is not documented in objective 
physical examination findings to confirm. The enrollee does not have a unique characteristic that would 
indicate a segmented pump over a standard pump. There was no documentation of a trial and failure of a 
standard pump to justify this request. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee has tried and failed Xarelto. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablet.  
 Benefits for Eliquis 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the consultation services provided on August 31, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that this 
service is not a Medicare covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services at issue by a contract provider. The file does not show that the Plan provided 
notice that the services provided would not be covered. Under Medicare rules, this means the services provided 
is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the consultation services 
provided on August 31, 2021.  
 
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 pre-approve the pneumatic compressor and segmental pneumatic 
appliance (CPT code(s): E0651RR and E0667NU). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the notes do not show that the enrollee has completed a six-month trial of conservative 
therapy. 
 
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 DME. Our physician reviewer 
found the provided documentation did not clearly describe the enrollee having tried and failed at least 6 months 
of conservative treatments for their condition before considering this device. The records did not meet LCD 
requirements for Medicare coverage. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the pneumatic compressor and segmental pneumatic appliance (CPT code(s): E0651RR and 
E0667NU).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NPWT electrical pump, stationary or portable (CPT 
code E2402). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the NPWT is being denied because the enrollee has been on it for more than four (4) 
months. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee has been using the NPWT already for more than 4 months and no 
longer meets Medicare criteria for ongoing use of this device. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve NPWT electrical pump, stationary or portable (CPT code E2402).