Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dopamine Transporter Single Photon Emission 
Computed Tomography (SPECT-DAT) (78830). 
 
You asked the Plan to pre-approve the SPECT-DAT scan. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that single photon emission computed tomography is 
covered when 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 SPECT-DAT scan. Our reviewer 
says that the requested imaging is not medically necessary. Our physician reviewer found there is no indication 
of concern for Essential Tremor. A SPECT-DAT scan is indicated for distinguishing between Parkinson's 
Disease and essential tremor. In this instance, the provider does not assert that essential tremor is a 
consideration. 
 
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 SPECT-DAT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Dopamine Transporter Single Photon Emission Computed Tomography (SPECT-
DAT) (78830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that you disagree with the Plan's denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inversion table fitness item purchased on October 12, 
2022. 
 
You asked the Plan to pay for the inversion table fitness item. You say that you would like reimbursement for 
this service. The Plan denied your request. The Plan says this item is not eligible for payment through your 
Pick Your Perks benefit. 
 
The rules say that Medicare does not cover gym benefits or over-the-counter items. However, the Plan offers a 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 The item at issue in this case is considered a piece of workout equipment or an over-the-counter item. 
However, fitness equipment is not among the list of items/services eligible for coverage under the Plans Pick 
Your Perks benefit, and this item is not on the Plans list of allowed over-the-counter items. Therefore, we 
decided that the Plan does not have to pay for the inversion table fitness item purchased on October 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient behavioral health custodial care. 
 
You asked the Plan to pre-approve additional custodial care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee is receiving custodial care. The Plan also says custodial 
care is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional custodial care have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
additional inpatient behavioral health custodial care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service November 7, 
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 11730. 
 
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 11730. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an iTind System (53899, C9769). 
 
You asked the Plan to pre-approve the placement of an iTind System. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 placement of an iTind System. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the use of a temporarily implanted nitinol device (e.g., iTind) is considered 
investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further 
studies are needed to evaluate the durability of iTIND. 
 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 placement of an iTind System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of an iTind System (53899, C9769).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 9, 2023. 
 
You asked the Plan to pay for an eye refraction. You say that this service was necessary. The Plan denied your 
request. The Plan says this is not covered.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for an eye refraction (92015) provided on January 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening (G0105) provided on October 
25, 2022. 
 
You asked the Plan to pay for the colorectal cancer screening. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that history codes, either family or personal, should 
be sequenced after the reason for encounter.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the colorectal cancer screening have not been met. Specifically, a family history code was 
sequenced as the primary diagnosis on this claim when it should be listed as a secondary diagnosis following a 
reason for encounter. Therefore, we decided that the Plan does not have to pay for the colorectal cancer 
screening (G0105) provided on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items should be covered because 
the member has been diagnosed with a bladder disorder. The Plan denied your request. The Plan says 
incontinence supplies are not covered under the patient's medical benefits. The Plan says that the member can 
contact their state Medicaid administrator to see if coverage exists under their Medicaid benefits. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
7, 2022, to December 8, 2022. 
 
You asked the Plan to pay for the subsequent hospital care 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. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed with 
primary diagnosis code F05 (delirium due to known physiological condition). This diagnosis has a "code first" 
note, which means the underlying condition should be sequenced first as the primary diagnosis. The claim is 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of the subsequent 
hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care services provided on December 7, 2022, to December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Barostim Neo system was approved 
by the Food and Drug Administration (FDA) in 2019 for patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are New York Heart Association 
(NYHA) Class III, have an ejection fraction less than 35 percent, and are not candidates for bi-ventricular 
pacing. However, there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system is not considered medically reasonable and 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 a Barostim Neo system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buprenorphine 5mcg/hour patch. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried multiple medications in 
the past but is allergic to codeine as well as hydrocodone. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
 
 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 buprenorphine 5mcg/hour 
patch.  
 
Benefits for the medication 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (HHS) provided from July 2, 2022, 
to July 8, 2022. 
 You asked the Plan to pay for home health services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the enrollee is not receiving any skilled nursing care, 
physical therapy, occupational therapy, or speech therapy; therefore, 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 reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that there is no evidence 
that the enrollee required or received home health skilled services during the dates of services in question. 
There is no evidence that the services of a home health aide were required to assist in the treatment of an acute 
illness or injury.  As such, the HHS are not medically necessary, reasonable or coverable. 
 
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 (HHS) provided from July 2, 2022, to July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
22, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 22, 2022.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that Orencia is a medical necessity for you. The Plan 
denied your request. The Plan says that step-therapy rules for coverage of Orencia 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 Orencia. Our reviewer says that the 
requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Kineret and Stelara before they will approve the requested drug. However, in this case 
the requested medication was first prescribed in September 2022 and the records provided indicate that you 
have been receiving the requested drug since that time. Step therapy may only be applied to new prescriptions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Orencia.  
 
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 the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there was no qualifying blood gas study done. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is payable. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on December 5, 2022.