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

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic pharmacogenomic test (81479) 
provided February 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that based on the peer-reviewed literature and 
technology assessment, Medicare has been covering the test as reasonable and medically necessary since 
October 24, 2014. The Plan denied your request. The Plan says GeneSight Psychotropic has not been shown to 
be useful and is noncovered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the GeneSight Psychotropic pharmacogenomic test (81479) provided February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the criteria for coverage 
has not been met. 
 
 
 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 Prolia. Our reviewer says that Prolia is 
not reasonable and necessary. Our physician reviewer found there is no indication that the enrollee has tried 
and failed the required drug(s). The enrollee is unable to take an oral bisphosphonate due to their 
gastrointestinal condition. Our reviewer found that there is no indication that intravenous Zoledronic acid 
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also 
found that the enrollee is reported to have a history of renal insufficiency, but records do not clarify the severity 
of this condition to preclude the use of Zoledronic acid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 12, 2022, to March 
24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 wound care services provided on January 12, 
2022, to March 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 17, 2021 billed 
with codes 81223, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81292, 81306, 81328, 81335, 
81350, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
December 17, 2021 billed with codes 81223, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 
81292, 81306, 81328, 81335, 81350, 81408 and 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the vessel in 
the chest. 
 You asked the Plan to pre-approve the chest MRA. You say that the enrollee needs this imaging to evaluate the 
cause of the leg swelling. The Plan denied your request. The Plan says the enrollee does not have a covered 
indication for this testing. 
 
The Plan follows Medicare rules. Medicare rules say that MRA may be considered reasonable and necessary 
for certain conditions as described in the Medicare rules section of this decision. 
 
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 chest MRA. Our reviewer says that 
the requested imaging is not shown to be reasonable and necessary in this case. Our physician reviewer found 
the enrollee is a 53-year-old man with a listed diagnosis of Localized swelling, mass and lump, lower limb, 
bilateral. His medical history is notable for hypertension, bladder cancer treated with neoadjuvant 
chemotherapy, cystoprostatectomy, bilateral pelvic lymph node dissection, and neobladder creation, severe 
malnutrition, chronic kidney disease, spinal disorder, edema of the left upper extremity, major depressive 
disorder, chronic pain, generalized anxiety disorder, neuropathy, and generalized weakness. The enrollee was 
evaluated in the vascular surgery on 7/22/22 for bilateral lower extremity swelling. The enrollee denied chest 
pain and shortness of breath. Bilateral deep vein blood clot studies were to be obtained. An MRA of the chest 
was ordered. The available documentation does not support that an MR angiogram of the chest was medically 
reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chest MRA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance angiography (MRA) of the vessel in the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on February 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 outpatient mental health provided on February 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram provided on February 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an echocardiogram. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 an echocardiogram provided on February 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita skin substitute. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that skin substitutes for non-healing wounds are 
covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has diabetes and bilateral leg amputation with stump infections requiring antibiotics and wound care. The wound are documented as have 
exudate and necrotic tissue. The criteria for coverage requires the absence of exudate and necrotic tissue; 
therefore, the services cannot be considered medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Revita skin substitute.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the soft tissue neck (70491). 
 
You asked the Plan to pre-approve a CT of the soft tissue neck. The Plan denied your request. The Plan says 
that this request does not meet the criteria for coverage because no ultrasound was provided, nor was any 
detailed clinical information provided regarding assessment. 
 
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 of the soft tissue neck. Our 
reviewer says that a CT of the soft tissue neck is medically reasonable and necessary. Our physician reviewer 
found the enrollee was described as severely obese, thus making them not an ideal candidate for an ultrasound. 
Our reviewer also found that the presence of prominent lymph nodes in the submandibular area of the neck 
makes the CT a reasonable 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 a CT of the soft tissue neck have been met. Therefore, we decided that the Plan 
has to pre-approve a computed tomography (CT) of the soft tissue neck (70491).  
 
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 compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under the enrollee's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo tablets. 
 
You asked the Plan to pre-approve Livalo tablets. You say that the enrollee was given drug samples, and this 
drug is a benefit to the enrollee. The Plan denied your request. The Plan says Livalo is a self-administered drug, 
covered by the pharmacy (drug) benefit. 
 
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 Livalo tablets.  
 
 
 
 
  
Benefits for Livalo tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation 
device. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-
acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vascular surgery follow-up consultation to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON vascular surgery follow-up. You say that this should be approved 
as the enrollee should not have care delayed. The Plan denied your request. The Plan says the enrollee has been 
enrolled with the current plan since April 1, 2022. The plan network has multiple vascular surgeons within 
reasonable time/distance of the enrollee's home address who can provide this routine follow-up care. There is 
no evidence that only the requested OON provider can safely provide this care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The enrollee has been a member of this 
Plan since April 2022. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a vascular surgery follow-up consultation to 
be provided by an out-of-network (OON) provider.
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 this is the safest discharge plan, allowing 
the highest potential for the enrollee's recovery, preventing further deterioration and the best use of medical 
management. The Plan denied your request. The Plan says based on Medicare guidelines and the information 
we have about the enrollee's condition they do not meet all the requirements. 
 
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 was admitted to the acute care hospital with pneumonia and non-healing 
lower extremity wounds complicated by methicillin-resistant staphylococcus aureus bacteremia requiring 
surgical debridement and other wound care, wound vac, intravenous antibiotics, and pain medications.  
 
 Recent notes describe the enrollee responding to current treatment with stable vitals but still requiring pain 
meds and intravenous antibiotics until September 15, 2022. The enrollee appears to be stable and improving 
and should only be completed at the current facility until more appropriate for a lower level of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional home health visits. You say that you have been receiving 
these services which have been helpful. You believe that the services should continue. The Plan denied your 
request. The Plan says you have had functional improvement, and therapy in the home is no longer required. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 additional home health visits. Our 
reviewer says that the documentation does not support the medical necessity of the requested home health 
services. Our physician reviewer found there is no documentation that an additional 16 home health physical 
therapy visits are required to effectively provide treatment, care, and/or services in order to improve the 
enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of 
function and/or prevent deterioration. As of 08/03/2022 the enrollee was walking 425 feet with a single point 
cane with stand-by to contact guard assistance and was managing steps and unlevel surfaces. She was contact 
guard assist to transfer in/out of a car/van. Based on the available records the patient appears to have improved 
with therapy to the point of being able to manage household ambulation safely. After the therapy treatments 
provided thus far, records do not support that the complexity of the patient's conditions are such that the skills 
of a professional therapist are required to achieve further improvement in the patient's symptoms or functional 
status, or to maintain the current functional status. Further utilization of the home exercise program or 
outpatient physical therapy appears appropriate at this point. 
 
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 additional home health visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional 16 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 laboratory services provided on February 22, 
2022, by an out-of-network (OON) provider.