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

 
We decided that the Plan does not have to pay for the genetic testing provided on February 10, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was 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. The panel was billed with multiple codes on multiple claims. 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 February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 provided February 25, 2022. 
 
You asked the Plan to pay for the diagnostic laboratory services. You say that you are requesting review of the 
documents and full allowance of the list price for Guardant360 against the enrollee's in-network benefits. The 
Plan denied your request. The Plan says the criteria has not been met as the enrollee had this same exact test 
(Guardant360) for the diagnosis of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the enrollee had this same test (Guardant360) 
for the diagnosis of prostate cancer on date of service September 23, 2021. Medicare rules says that diagnostic 
genetic testing for a disease should be performed once in a lifetime. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 provided February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect testing (0012M) provided on January 31, 
2022. 
 
You asked the Plan to pay for CxBladder detect testing. You say that these services were necessary and 
reasonable. The Plan denied your request. The Plan says this testing is not covered by Medicare. In addition, 
after consideration of the literature, National Comprehensive Cancer Network (NCCN) rating and clinical 
relevance, this panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder 
testing are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the requested testing 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for CxBladder 
Detect testing (0012M) provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve median branch block (MBB) (64493, 64494, 64495). 
 
You asked the Plan to pre-approve the MBB. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested services are not 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 MBB. Our reviewer says that the 
requested medial branch block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate that the enrollee has performed six weeks of 
physical therapy. The reviewer also found that the enrollee has been experiencing left leg radicular symptoms. 
Therefore, the reviewer found that the requested medial branch block (MBB) is not medically reasonable or 
necessary at this time. 
 
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 MBB have not been met. Therefore, we decided that the Plan does not have 
to pre-approve median branch block (MBB) (64493, 64494, 64495).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
November 7, 2021. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. The Plan denied your request. The Plan says 
procedure code 99100 and 99140 is considered bundled and not separately payable. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
November 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair with 2 or more power seat 
options and accessories (K0861, E2609, E2361, E2377, E2617, E2313, E2323, E1028, E1002, E2300, E0955, 
E1012, K0040, E0705, E0960). 
 
You asked the Plan to pre-approve a special power wheelchair and accessories. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says the requested power 
wheelchair is medically necessary when a person has need for power tilt and power recline. The notes do not 
show that the enrollee has a medical need for these power options. The Plan also says the enrollee does not 
meet criteria for the requested power wheelchair. 
 
 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 special power wheelchair and 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living 
such as toileting, feeding, grooming and bathing in customary locations within the home. There is no 
documentation that the group 3 power wheelchair with 2 or more power seat options (power tilt and seat lift) 
and accessories at issue in this case meets Medicare criteria for medically reasonable and necessary. The 
requested power seat lift feature is statutorily non-covered as it serves no primary medical purpose, thus the 
multiple power options feature is not covered. As the group 3 power wheelchair with multiple power options 
does not meet criteria for coverage, none of the requested accessories are covered. 
 
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 special power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a special power wheelchair with 2 or more power seat 
options and accessories (K0861, E2609, E2361, E2377, E2617, E2313, E2323, E1028, E1002, E2300, E0955, 
E1012, K0040, E0705, E0960).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested Synvisc-One is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Euflexxa first. 
 
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 Synvisc-One. Our reviewer says that 
the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the hip. The Medicare approved compendium, DrugDex, indicates that there is a 
strong recommendation against the use of the requested drug for the noted indication. Notwithstanding that 
fact, the enrollee does not satisfy the plan's step therapy criteria. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation One CDX testing provided on June 4, 2021. 
 
You asked the Plan to pay for the Foundation One CDX testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 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. 
 
Review of the file shows that the documentation does not show how the results would affect seeking further 
cancer treatment. This means the testing at issue 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 Foundation One CDX testing provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve the injections. You say that the requested injections are medically 
necessary. The Plan denied your request. The Plan says the provided documentation does not indicate that the 
criteria have been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all criteria. 
 
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 injections. Our reviewer says that 
the requested injections do not meet the criteria for coverage. Our physician reviewer found the provided 
documentation does not include enough physical exam detail to support either the facet blocks or the sacroiliac (SI) injection. The reviewer found that fundamental exam findings such as range of motion limitations, motor 
strength, and distraction tests, FABER, are not documented. Therefore, at this time, the requested injections are 
considered 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the documentation does not support that you have a neuromuscular disease, thoracic restrictive 
disease, or chronic respiratory failure consequent to COPD. The documentation does not support that the 
ventilator at issue is medically necessary and reasonable for you. There is no documentation of trial and failure 
of BiPAP with AVAPS. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this would be beneficial in treating the 
enrollee's condition. The Plan denied your request. The Plan says this is an experimental procedure. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for back pain. More research is needed to 
show safety of efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 
88112 provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 88361, 88312, 88305, and 88112 are not supported in the medical record. Specifically, 
these codes have a physician Fee Schedule professional component/technical component indicator of 1. The 
claim has a place of service of 22, Outpatient hospital. The professional interpretation was furnished in the 
same payment locality from where the technical component was furnished. We find that the Medicare rule for 
payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting physician. 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 laboratory services coded 88361, 88312, 88305, and 88112 provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve beta-tricalcium phosphate allograft (20930), bone 
marrow aspirate (20939), and bacfuse Interlaminar Fixation system (22842). 
 
You asked the Plan to pre-approve beta-tricalcium phosphate allograft (20930), bone marrow aspirate (20939), 
and bacfuse Interlaminar Fixation system (22842). You say that the requested beta-tricalcium phosphate 
allograft (20930), bone marrow aspirate (20939), and bacfuse Interlaminar Fixation system (22842) are 
medically necessary. The Plan denied your request. The Plan says the requested beta-tricalcium phosphate 
allograft (20930), bone marrow aspirate (20939), and bacfuse Interlaminar Fixation system (22842) are not 
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 beta-tricalcium phosphate allograft 
(20930), bone marrow aspirate (20939), and bacfuse Interlaminar Fixation system (22842). Our reviewer says 
that the requested beta-tricalcium phosphate allograft (20930), bone marrow aspirate (20939), and bacfuse 
Interlaminar Fixation system (22842) are not medically necessary. Our physician reviewer found the intralaminar fixation device and bone marrow aspirate and beta tricalcium graft are all experimental and not 
clinically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of beta-tricalcium phosphate allograft (20930), bone marrow aspirate (20939), and 
bacfuse Interlaminar Fixation system (22842) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve beta-tricalcium phosphate allograft (20930), bone marrow aspirate (20939), and bacfuse 
Interlaminar Fixation system (22842).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11721 is bundled into payment for code 11056.  
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 11721 
is a column II code to column I code 11056. 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 11721 billed for date of service March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure 
(BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the documentation does not support that you have a neuromuscular disease, thoracic restrictive 
disease, or chronic respiratory failure consequent to COPD. The documentation does not support that BiPAP 
with a backup rate and average volume-assured pressure support (AVAPS) has been tried and failed or is likely 
to fail. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 
You asked the Plan to pre-approve Epogen. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Procrit or Retacrit. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Epogen. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed at least one of the plan's preferred step one alternatives. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen (J0885).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36410 billed for date of service November 
15, 2021. 
 
You asked the Plan to pay for procedure code 36410. You say that these services were reported correctly. The 
Plan denied your request. The Plan says payment for code 36410 is bundled into payment for code 71275. 
 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 36410 
is a column II code to column I code 71275. 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 36410 billed for date of service November 15, 
2021.