Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005), back cushion (E2611), and seat cushion (E2601).

You asked the Plan to pre-approve an ultra-lightweight manual wheelchair, back cushion, and seat cushion. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met:

1. The beneficiary must be a full-time manual wheelchair user.

2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair.

3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The LCMP may have no financial relationship with the supplier.

4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.

If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and 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 an ultra-lightweight manual wheelchair, back cushion, and seat cushion. Our reviewer says that the items are not medically necessary. Our physician reviewer found you do not have need for specialized fitting on a wheelchair.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultra-lightweight manual wheelchair, back cushion, and seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005), back cushion (E2611), and seat cushion (E2601).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Y90 radioembolization. 
 
You asked the Plan to pre-approve Y90 radioembolization. You say that this is the most clinically appropriate 
option for the enrollee's condition. The Plan denied your request. The Plan says this treatment is proven to be 
ineffective. 
 
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 Y90 radioembolization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the technique of radioembolization for liver metastases itself is not investigational. 
For the enrollee, quality of life could be substantially improved with this technique. It may not prolong life and 
certainly will not cure the condition, but it has a reasonable likelihood of preventing or delaying symptomatic progression. Because of progressive bulky liver disease that is imminently life-threatening, radioembolization 
could be within accepted standards of care. However, an August 25, 2023 clinic note explicitly states that the 
enrollee is planning to initiate a new systemic therapy within the next month. Another note states that 
radioembolization would be considered pending response to new systemic therapy about to be initiated. The 
option of holding off on this therapy was also discussed, though it is evidence that standard of care systemic 
therapies remain an option for this 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 Y90 radioembolization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Y90 radioembolization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the outpatient diagnostic and medication services 
provided on March 25, 2023. 
 
You asked the Plan to further pay for the services provided. You say that the correct amount was not 
reimbursed. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copay for lab services for outpatient diagnostic tests.  
 
The file shows that the Plan reimbursed the Medicare allowed amount minus the applicable copay for the lab 
services. The services fall within the outpatient diagnostic tests benefit category. The file also shows that you 
received medications, such as Dextromethorphan, Paracetamol, and Molnupiravir. These self-administered 
drugs are not among the types which are covered by Medicare Part B. We found no exception which would 
require the Plan to further pay for the services provided. Therefore, we decided that the Plan does not have to 
further pay for the outpatient diagnostic and medication services provided on March 25, 2023.  
 
Benefits for the services provided 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 T7, T12, and L3 kyphoplasty (22513, 22514, 22515). 
 
You asked the Plan to pre-approve T7, T12, and L3 kyphoplasty. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T7, T12, and L3 kyphoplasty. Our 
reviewer says that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging corroboration of other plausible causes of the back 
pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T7, T12, and L3 kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve T7, T12, and L3 kyphoplasty (22513, 22514, 22515).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a percutaneous transcatheter closure of the left atrial appendage 
with endocardial implant and radiological supervision and interpretation (33340). 
 
You asked the Plan to pre-approve a left atrial appendage implant. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
that the request is not medically necessary because the records do not show evidence of a formal shared 
decision-making interaction with an independent non-interventional physician using an evidence-based 
decision tool on oral anticoagulation in the enrollee's medical records. 
 
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 a left atrial appendage implant. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is being considered for a LAA procedure. The documentation 
clearly shows that the enrollee has a CHADS2VASC score of 3 and therefore, meets LCD criteria for an LAA 
procedure as requested. 
 
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 left atrial appendage implant have been met. Therefore, we decided that the 
Plan has to pre-approve a percutaneous transcatheter closure of the left atrial appendage with endocardial 
implant and radiological supervision and interpretation (33340).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service March 23, 
2022.  
 
You asked the Plan to pay for procedure code 88374. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. The documentation does not provide sufficient rationale as to the reason the excess 
units were needed. Based on this information, we decided that Medicare rules for coverage of procedure code 
88374 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 
billed for date of service March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 24, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 
April 24, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81479.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 You asked the Plan to pre-approve Supartz. You say that you do not buy and bill step one agents and only have 
Supartz on hand as buy and bill. You say that the enrollee has tried cortisone injection and has had some relief.  
The Plan denied your request. The Plan says that the step therapy requirements have 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 Supartz. Our reviewer says that Supartz 
is not medically necessary. Our physician reviewer found that there are no contraindications or reasons the 
preferred viscosupplemental treatments were not considered or that the Plan's additional required drugs would 
likely be less effective 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that a study like the one requested has already been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the provider's notes on appeal indicated that a prior 
approval had previously been granted, but the approved study was never performed. In such a case, an 
extension of the prior approval would be appropriate. The requested study for an unresected meningioma 
would be consistent with current recommendations, given that the most recent imaging had been 2 years prior. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the brain.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to an LTACH is not medically necessary. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are appealing the denial of services. The Plan 
denied your request. The Plan says the services are not authorized because Puget Sound Chiropractic LLC, is a 
non-network provider who does not work with the enrollee's health Plan. 
 
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 office visit provided on March 9, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided out-of-area 
on September 12, 2022. 
 You asked the Plan to pay for the chiropractic manipulative treatment provided out-of-area. You say that you 
thought you had full coverage outside of the county. The Plan denied your request. The Plan says you must go 
to an in-network provider. There are in-network options available. We could not review for medically necessity 
because no medical records were received. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 chiropractic manipulative treatment. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that you received chiropractic services from an out of network provider. The record provided does not support 
that the services were of an urgent or emergent nature. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for the chiropractic manipulative treatment provided out-of-area on 
September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test billed for date of service March 29, 2023. 
 
You asked the Plan to pay for the billed services. You say that peer-reviewed publications support the testing. 
The Plan denied your request. The Plan says the test is non-covered. 
 
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. In this case, the provided testing is not a covered benefit. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test billed for date of service March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NanOss 3-dimensional (3D) allograft (20930). 
 
You asked the Plan to pre-approve the NanOss 3D allograft. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of the NanOss 3D 
allograft in the setting of lumbar spine fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 NanOss 3D allograft. Our reviewer says that the requested NanOss 3D allograft is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that 
shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies 
are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested NanOss 3-dimensional (3D) allograft 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 the NanOss 3D allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve NanOss 3-dimensional (3D) allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) U0003 billed for date of service February 
2, 2022. 
 
You asked the Plan to pay for procedure code(s) U0003. You say that please reconsider these claims for 
payment. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code U0003 has a Professional/Technical indicator of 1. This means that CPT code U0003 has 
both a professional and technical component. In this case, CPT code U0003 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code U0003 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) U0003 billed for date of service February 2, 2022.