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

 
We decided that the Plan does not have to pay for drug testing (G0482) provided to the enrollee on October 20, 
2022. 
 
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 do not support that 15-21 drug classes were tested. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any 
type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic 
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in 
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method 
or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument 
variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, 
per day; 15-21 drug class(es), including metabolite(s) if performed." 
 
We find that procedure code G0482 is not supported in the medical record. Specifically, this code requires 
documentation of 15-21 drug classes being tested. The records only show nine drug classes being tested. 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 drug testing (G0482) provided to the enrollee on October 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the denture. You say that you disagree with the denial for a mandibular 
denture. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 14, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
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 the enrollee is medically stable for 
transfer, deserves the best outcome to return to prior level of function and LTACH is the appropriate level of 
care. The Plan denied your request. The Plan says the enrollee records does not meet the criteria for LTACH 
and may be safely met at a skilled nursing facility. 
 
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 medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this due to worsening heart 
failure. The Plan denied your request. The Plan says there is not enough evidence that this would improve the 
enrollee's outcome. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will not be able to regain maximum mobility 
without an IRF. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be provided safely in other settings. 
 
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 you do not have any complex functional deficits or active medical issues. Your 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight testing (81479) provided on October 3, 2022. 
 
You asked the Plan to pay for the Genesight testing. You say that the provided Genesight testing was medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided 
Genesight testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Genesight testing. Our reviewer says that 
the enrollee did not meet criteria for the provided Genesight testing. Our physician reviewer found the 
reviewed documentation indicates that the test was ordered for the diagnoses of anxiety disorder (ICD-10 code 
F41.1) and Insomnia (ICD-10 code G47.00). Though the Genesight Order Medical Necessity Documentation 
form stated that Abilify (Aripiprazole) and Elavil (Amitriptyline) were being considered for augmentation or 
starting/switching to, and Ativan (Lorazepam) was being considered for dose adjustment, there is no 
documentation of such provided in the medical records sent for review. There is no indication from the clinical 
record that the provider has already considered non-genetic factors to make a preliminary drug selection. The 
review has determined that the enrollee did not meet the LCD criteria for the provided Genesight testing. 
 
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 Genesight testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Genesight testing (81479) provided on October 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultraviolet light therapy (96900) with an ultraviolet 
cabinet (E0694). 
 
You asked the Plan to pre-approve therapy with an ultraviolet cabinet. You say that the requested 
items/services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items/services are not a covered benefit in this case. 
 
The Plan covers all items that Medicare covers. Medicare rules state that ultraviolet cabinets are covered for 
selected patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy with an ultraviolet cabinet have not been met. Specifically, the available medical records 
do not support a diagnosis of generalized intractable psoriasis. Therefore, we decided that the Plan does not 
have to pre-approve ultraviolet light therapy (96900) with an ultraviolet cabinet (E0694).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint (64635). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says radiofrequency ablation used for sacro-iliac joint pain is considered not 
medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The rules say that radiofrequency 
ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed 
using traditional, cooled, or pulsed radiofrequency. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation to the SI joint (64635).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sandostatin Lar Depot. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under 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 Sandostatin Lar Depot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says picture studies are not needed to guide this type of treatment. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. Usually, IGRT 
is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to this patient for which the target lesion can be seen on the skin to assist in 
daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being 
treated. Billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice." 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided radiation therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says there is no record that the enrollee tried on of the 
preferred drugs and it hasn't worked or that the enrollee has medical reasons that prevent them from using one 
of the preferred 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 Evenity. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs Prolia 
and Reclast before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom shoe inserts (L3000). 
 
You asked the Plan to pre-approve the custom shoe inserts. You say that the custom shoe inserts are necessary 
due to foot pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the custom shoe inserts (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 99233) 
provided to the enrollee on June 10, 2022. 
 
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 service is not supported without the required documentation. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care service provided by a healthcare provider, requiring a medically appropriate history and/or examination 
and a high level of medical decision making and the total time spent on the encounter is at least 50 minutes." 
 
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 there is no progress note for this 
date of service. It cannot be verified that subsequent inpatient care was provided to this patient on this date. 
 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 subsequent nursing facility care (procedure code 99233) provided to the enrollee on June 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture - flexible base (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures broke. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 17, 2021. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture - flexible base 
(D5225).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that this procedure 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 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 total knee arthroplasty. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found documentation does not show a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures (including viscosupplementation or any formal 
physical therapy) for the right knee. Additionally, the x-rays provided noted moderate degenerative changes in 
the medial compartment and no indication of severe pathology of the right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total knee arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brilinta tablet 90mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Brilinta tablet 90mg.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is being dispensed by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gamunex-C.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines would not support the necessity of these procedures at this point in the 
management of her chest pains. In summary, there is insufficient documentation to support the medical 
necessity of cardiac catheterization 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) received from 
March 31, 2022, to April 26, 2022. 
 
You asked the Plan to pay for the device. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. 
 
The requested device is not covered by Medicare at this time. 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 pay for a pneumatic compression device (E0675) received from March 31, 2022, to April 26, 2022.