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

 
We decided that the Plan does not have to pay for the Omnigraf testing (0118U, 81479). 
 
You asked the Plan to pay for the Omnigraf testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing is investigational. 
 
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 pay for the Omnigraf testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no reason given for clinical suspicion of acute rejection. The mild change in creatinine (kidney function) is blamed on being dehydrated. The enrollee had a biopsy performed in 2020 with 
no signs of rejection.  There does not appear to be a high suspicion for rejection. It does not appear that this 
enrollee would be routinely biopsied. The purpose of this test is to avoid the invasive procedure of the kidney 
transplant biopsy. There appears to be a low clinical suspicion for rejection based on the information provided. 
Thus, this testing does not appear to be medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Omnigraf testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Omnigraf testing (0118U, 81479).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on March 15, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have supplied medical records to support 
payment. The Plan denied your request. The Plan says that medical records were not provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that no medical records were 
provided.  However, you supplied full medical records with your appeal request.  The Plan has failed to review 
these records and make a determination.  The burden is on the Plan to show why its denial is correct.  By 
failing to review and address the medical records supplied, we find that the Plan has failed to meet this burden. 
Therefore, we decided that the Plan has to pay for medical services provided on March 15, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that Feraheme is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Feraheme 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 Feraheme. Our reviewer says that 
treatment with Feraheme is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64450, & 73140 provided on May 18, 2023. 
 
You asked the Plan to pay for procedure codes 64450, & 73140. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the codes billed are 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. 
 
We find that CPT code 64450, & 73140 is not supported in the medical record. Specifically, code 64450 is a 
column II code to column I code 20610 which was also billed. Code 73140 was missing a required anatomical 
modifier. Based on this information, we decided that Medicare rules for coverage of procedure codes 64450, & 
73140 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 64450, 
& 73140 provided on May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, of genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this service is considered an experimental therapy and the subject of ongoing clinical trials. 
Therefore, the request is deemed not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the destruction by neurolytic agent, of genicular nerve branches including imaging 
guidance, when performed (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab (Imfinzi) (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that this patient qualifies for this administration. You also 
say that they have already received platinum-based therapy and then had surgery. The Plan denied your 
request. The Plan says the use of Imfinzi for stage IVA non-small cell lung cancer (NSCLC) is not FDA 
approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 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 Imfinzi. Our reviewer says that this 
request is not medically reasonable and necessary. Our physician reviewer found the requested use of 
durvalumab (Imfinzi) (J9173) is not FDA-approved for the enrollees diagnosis. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS) approved medical journal. Our reviewer also found that the use is not listed as not indicated, 
not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve durvalumab (Imfinzi) (J9173).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services. 
 
You asked the Plan to pre-approve psychotherapy services. You say that that psych visits may do more harm 
than good. The Plan denied your request. The Plan says home physician visits are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of psychotherapy services have been met. Medical records have not been provided. Therefore, we decided that the Plan does not have to pre-approve 
psychotherapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2023, billed with 
codes 87481, 87500, 87640, 87641, 87653 and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. 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 
March 2, 2023, billed with codes 87481, 87500, 87640, 87641, 87653 and 87798.
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 enrollee has been to this IRF previously, and 
would like to come back to the facility. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility.  
 
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 enrollee was admitted for dysphagia and dehydration. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. 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.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital from  
May 6, 2023, to May 8, 2023. 
 
You asked the Plan to pay for the medication. You say that the enrollee had not anticipated being admitted to 
the hospital and did not bring her medication from home. 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 pay for self-administered drugs provided 
in the hospital from May 6, 2023, to May 8, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impression casting of a foot (S0395) and foot, insert, 
removable, molded to patient model (L3000). 
 
You asked the Plan to pre-approve the foot orthotics. You say that the patient needs this because they are in 
pain. The Plan denied your request. The Plan says these items are not covered benefits. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve an 
impression casting of a foot (S0395) and foot, insert, removable, molded to patient model (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #14 and a retainer crown 
(D6740) for tooth #13 and #15. 
 
You asked the Plan to pre-approve the dental service. You say that other dental work was approved, and the 
Plan should approve the bridge. The Plan denied your request. The Plan says the denial of authorization for the 
bridge is correct, because the x-rays did not show that your gums and bones were satisfactory to have the dental 
services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 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 dental service. Our reviewer says 
that the bridge is not medically necessary. Our physician reviewer found that there was a panoramic x-ray 
dated August 7, 2023. Tooth #14 is not present in the enrollees mouth. Tooth #13 has moderate to severe bone 
loss, and tooth #15 has severe bone loss. There were no clinical notes included, nor was there a periodontal 
chart. A bridge should not be placed on teeth with severe bone loss, as the teeth can potentially become 
infected, or loose necessitating extraction. The teeth anchoring the bridge must have enough bone for support 
of the bridge. The bridge has a poor prognosis based on the bone loss noted from the x-ray submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6245) for tooth #14 and a retainer crown (D6740) for tooth #13 and #15.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided on April 5, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 code 99284 is not supported in the medical record. Specifically, diagnosis code Z13.9, 
encounter for screening, unspecified, is not supported. Routine screening is not performed in the emergency 
room setting. The records show this was a diagnostic examination. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99284) provided on April 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate drug or zoledronic acid 
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 Prolia. 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 
age related osteoporosis without osteoporotic fracture. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 20930. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 20930 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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service November 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on June 15, 2023. 
 
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. There is no network deficiency for these services and alternate 
network providers were found. 
 
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 
service 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 June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the patient would benefit from massage 
therapy due to the past failed treatments. The Plan denied your request. The Plan says massage therapy is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology consultation to be provided by an  
out-of-network provider.  
 
You asked the Plan to pre-approve a cardiology consultation to be provided by an out-of-network provider. 
You say that you have been a patient with this provider since they found your heart condition and you would 
like to keep this doctor. The Plan denied your request. The Plan says the requested services are available in-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
cardiology consultation to be provided by an out-of-network provider.