Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of anemia of chronic renal disease. The documentation does not support that 
the enrollee has tried and failed Retacrit or Procrit therapy for at least two consecutive months even with 
appropriate dose adjustment. The documentation does not support that Retacrit or Procrit would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78812). 
 
You asked the Plan to pre-approve a PET scan. You say that you are requesting a fast appeal for the denial of a 
PET scan. The Plan denied your request. The Plan says that the records do not show the enrollee meets the 
criteria for the requested PET scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the requested PET scan will provide information 
about a potential site for biopsy in a patient whom lymphoma and metastatic disease remain in the differential 
diagnosis. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan (78812).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that the enrollee is being seen at 
your office for wound care. He has a deep wound on the left ankle and has to have minimal weight bearing. He 
was advised not to drive. The Plan denied your request. The Plan says you have exceeded your 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 72 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 thirty (30) additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HTT (huntingtin) (e.g., Huntington disease) gene testing 
(81271). 
 
You asked the Plan to pre-approve HTT gene testing. You say that you have family members with Huntington 
disease, so this test is necessary. The Plan denied your request. The Plan says this test is unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management, and therefore is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that testing for HTT is not considered medically reasonable and 
necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HTT gene testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve HTT (huntingtin) (e.g., Huntington disease) gene testing (81271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic limb evaluation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a prosthetic limb evaluation. You say that you have gone to several 
providers, and no one has seemed to be able to help you. You believe an OON provider can assist with your 
needs. The Plan denied your request. The Plan says you must receive care from a network provider unless the  
services are urgently needed or emergency 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. 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 prosthetic limb evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the requested therapy services are 
medically necessary. The Plan denied your request. The Plan says additional therapy is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that you have had extensive prior therapy, and the documentation does 
not support that the ongoing services requested are accepted as specific and effective treatment for your 
condition. The services do not require the ongoing skills and supervision of a professional physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ophthalmic ultrasound provided on April 20, 2023. 
 
You asked the Plan to pay for ophthalmic ultrasound. You say that this was medically necessary. The Plan 
denied your request. The Plan says that this was not medically necessary. 
 
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 pay for ophthalmic ultrasound. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a dense cataract and the posterior segment of the eye could not be visualized. 
The ultrasound was medically necessary to rule out posterior segment pathology prior to proceeding with 
cataract surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ophthalmic ultrasound have been met. Therefore, we decided that the Plan has 
to pay for an ophthalmic ultrasound provided on April 20, 2023.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested acute inpatient rehabilitation hospital 
stay is medically necessary. The Plan denied your request. The Plan says the inpatient rehabilitation facility 
(IRF) services you are requesting do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you are requesting reconsideration as 
you want to be able to walk. The Plan denied your request. The Plan says the service requested does not meet 
the requirements for approval. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0299, Q5001) provided on 
October 22, 2022, to November 20, 2022.  
 
You asked the Plan to pay for home health services. You say that the services should be covered as 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. 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 pay for home health services. Our physician 
reviewer found based on the record, the enrollee's needs were custodial. They did not have documented skilled 
nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services (G0299, Q5001) provided on October 22, 2022, to November 
20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Transthoracic Echocardiography 
provided on May 3, 2023. 
 
You asked the Plan to waive the copayment for the Transthoracic Echocardiography. 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 $150 
copayment for other outpatient diagnostic tests - radiological diagnostic services, not including x-rays.  
 
 You have been asked to pay a $150 copayment for the Transthoracic Echocardiography. This service falls 
within the other outpatient diagnostic tests - radiological diagnostic services, not including x-rays benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the Transthoracic Echocardiography provided 
on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Mis receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 Mis receiver.. You say that the medical records support the 
medical necessity for the CGM. The Plan denied your request. The Plan says the enrollee is not on insulin or 
does not have documentation of recurrent problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Dexcom G7 Mis receiver. Our 
reviewer says that the Dexcom G7 is not medically necessary. Our physician reviewer found coverage criteria 
for CGM require low blood glucose sugar or insulin use. The enrollee is not on any medications for blood 
glucose control. Criteria for the CGM are not met. We are not told why fingerstick monitoring would not 
suffice. 
 
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 Dexcom G7 Mis receiver 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 Mis 
receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20611, 73650, and 73660, and 99215 
rendered on August 9, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 20611: 
 
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
with ultrasound guidance, with permanent recording and reporting 
 
CPT 73650: 
 
Radiologic examination; calcaneus, minimum of 2 views 
 
CPT 73660: 
 
Radiologic examination; toe(s), minimum of 2 views 
 
CPT 99215: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using time 
for code selection, 40-54 minutes of total time is spent on the date of the encounter 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 20611 (Arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound 
guidance, with permanent recording and reporting) was requested. Although the documentation supports a 
medically appropriate history and physical, the records do not support a high level of decision making for this 
encounter to have a knee injection. There was no evidence in the documentation showing the report/recording 
of the ultrasound guidance used during the injection or the reason why it was required for a simple knee joint 
injection. Therefore, CPT 20611 and CPT 99215 are not supported. 
 
Additionally, in this case, we have confirmed that CPT 73650 and CPT 73660 are column II codes to column I 
CPT 73630. 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 for CPT 73650 and CPT 73660. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 20611, 73650, and 73660, and 99215 rendered on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 6, 2023. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says 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 Plan says that the Plan has also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a home visit provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 9, 2023, billed with 
codes 81433 and 81432. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
May 9, 2023, billed with codes 81433 and 81432.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 11, 2023, to April 20, 
2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that D64.81 has an Excludes1 note in relation to C92.00. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on April 11, 2023, to April 20, 2023.