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

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One (J7326). You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, 
Monovisc, or Synvisc-One. 
 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 Gel-One (J7326). 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 one of the plan's preferred drugs, Durolane, Monovisc, or 
Synvisc-One. The reviewer also found that the documentation does not support that Durolane, Monovisc, or 
Synvisc-One would likely be less effective, and/or would likely have adverse effects for the enrollee in this 
case. 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 Gel-One (J7326). have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gel-One (J7326).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity 
without contrast material (73700). 
 
You asked the Plan to pre-approve a CT scan. You say that the enrollee has tried and failed conservative 
treatments, and this CT scan is necessary to proceed with other treatment options. The Plan denied your 
request. The Plan says the criteria for a CT scan are not met in this case. The enrollee's x-rays do not show 
abnormal findings or that the enrollee has hardware in the knee from a previous surgery. In addition, this scan 
is requested to plan for robot assisted surgery, which is an investigational procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
requested imaging service is not medically necessary in this case. Our physician reviewer found that this 
enrollee was being treated for osteoarthritis of the left knee. He presented with left knee pain that is worsening 
and swelling in the knee. There is pain with ambulation. There is medial joint line tenderness. However, there 
is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the noted pathology. Improved overall knee function and/or pain relief have not been 
documented in this setting, in such studies. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
CT scan of the lower extremity without contrast, in this case, is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of the lower extremity without contrast material (73700).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick pen. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that the enrollee needs this drug. 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 Repatha SureClick pen.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee from December 4, 
2021, to December 12, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare first for review. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee from December 4, 
2021, to December 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient psychiatric services. You say that you live alone and do not have 
much support at home. You say that you remain depressed and are isolated. The Plan denied your request. The 
Plan says that the guidelines for coverage have not been met. The Plan says that the enrollee can be treated at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on June 18, 2022, with Major Depressive Disorder, 
Severe without Psychotic Features. Based upon review the records provided it was expected this enrollee 
would improve in a reasonable period of time for the dates in question. The patient was isolating and depressed 
without any assistance at home. It did appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she 
was isolating and depressed. It did appear that active treatment was taking place beyond the date in question. It 
did appear that the services were reasonably expected to improve the patients condition or for the purpose of 
diagnosis beyond the date in question. It did appear that the records were supervised and evaluated by a 
physician. 
 
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 psychiatric services have been met. Therefore, we decided that the 
Plan has to pre-approve inpatient psychiatric services.  
 
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: Favorable

 
We decided that the Plan has to pre-approve nose repair surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary The Plan denied your 
request. The Plan says that there is no evidence of trial and failure of other treatment. 
 
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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the available clinical documentation, the requested services for septoplasty and bilateral inferior 
turbinate reduction meet criteria for being medically necessary and reasonable. Clinical documentation 
included patient symptoms of nasal obstruction and snoring, as well as physical examination and computed 
tomography (CT) findings of a deviated nasal septum. A multicenter randomized controlled trial demonstrated 
that septoplasty with or without turbinoplasty was more effective than nonsurgical management for nasal 
obstruction in adults with a deviated nasal septum. In summary, the requested septoplasty and bilateral inferior 
turbinate reduction meet criteria for being medically necessary and reasonable. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve nose repair surgery.  
 
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 pay for the anesthesia for percutaneous image guided procedures on 
the spine and spinal cord (01936) provided on November 7, 2021. 
 
You asked the Plan to pay for the anesthesia for percutaneous image guided procedures on the spine and spinal 
cord. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied 
your request. The Plan says this claim has not been billed with an appropriate diagnosis according to Medicare 
rules. 
 
The Plan must follow Medicare rules. The rules state that diagnosis codes M47.26 and S79.911A are not listed 
as valid diagnosis codes for the anesthesia services coded 01936 
 
We looked at the file and Medicare rules. In this case, the diagnosis codes billed are not valid for payment of 
code 01936. Based on this information, we decided that Medicare rules for coverage of the anesthesia for 
percutaneous image guided procedures on the spine and spinal cord have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia for percutaneous image guided procedures on the spine and 
spinal cord (01936) provided on November 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on August 31, 
2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare first. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing services provided on November 5, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the billed codes were an extra scope service. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We looked at the file and the rules. The medical records provided do not show that the services billed with the -
59 modifier were a distinct procedural service. Specifically, the services were provided as visualization during 
arterial line and ventral venous line placements. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not 
have to pay for the diagnostic testing services provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision item or service, miscellaneous (V2799) provided 
February 8, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for routine eyewear. You say that you were told you could use your $100 allowance 
towards eyewear and made the decision to purchase the best ones for you. The Plan denied your request. The 
Plan says this service is not covered because it was not provided by a participating routine vision provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you obtain your eyewear from a provider in the Plans routine 
vision vendors network. 
 
We looked at the file and the Plan's rules. In this case you used a provider who does not participate in the 
Plans routine vision vendors network. Based on this information, we decided that the Plan's rules for coverage 
of routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
item or service, miscellaneous (V2799) provided February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve re-implantation of subcutaneous cardiac rhythm monitor 
(33285). 
 You asked the Plan to pre-approve the surgical procedure. You say that the requested procedure is medically 
necessary, and you are requesting reconsideration. The Plan denied your request. The Plan says the records do 
not support that the requested service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the implantable loop recorder (ILR) had been placed after an episode of syncope. No 
significant arrhythmias have been noted over the life of the device. As such, based on current guidelines and 
the documentation provided, there is insufficient clinical evidence to support the medical appropriateness and 
necessity of replacing the enrollees old ILR with a new ILR. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve re-implantation of subcutaneous cardiac rhythm monitor (33285).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve cardiac stress test. You say that the enrollee has had near syncope episodes 
along with chest pain. You say that a recent Holter and Echocardiogram were both noted to be normal. You 
also say that you would like to further evaluate with a myocardial perfusion exercise to rule out any ischemia. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated for 
certain situations. 
 
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 stress test. Our reviewer says 
that the requested cardiac stress test is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollees pre-test probability for an abnormal test is low and there is no 
documentation that his ECG shows an uninterpretable pattern. The reviewer found there was no evidence 
provided that would support the need for radionuclide stress testing. Therefore, the reviewer found that there is 
insufficient documentation to support the medical necessity for the requested cardiac stress test. 
 
 
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 stress test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for dialysis. The Plan denied your request. The Plan says that your request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next diabetic testing strips. 
 
You asked the Plan to pre-approve the Contour Next diabetic testing strips. You say that the items in dispute 
are medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail all 
preferred blood glucose testing products that are covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The records show that that brand of test strips being requested are not 
the Plan's preferred brand. There is no documentation showing that there is a medical reason these test strips 
cannot be used by the enrollee. Based on this information, we decided that Medicare rules for coverage of the 
Contour Next diabetic testing strips have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Contour Next diabetic testing strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical and anesthesia services rendered on January 21, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that services rendered to a registered inpatient must 
be billed with POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under hospital inpatient status 
and the claims were not billed with the required POS code 21. 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 pay for the surgical and anesthesia services rendered on 
January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 31, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC testing is not a covered 
benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 31, 2022.