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

 
We decided that the Plan does not have to pay for the wound panel provided on January 3, 2023, billed with 
codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651 and 87653. 
 
You asked the Plan to pay for the wound panel. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound panel have not been met. Specifically, the records show that this was a single panel 
which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to 
pay for the wound panel provided on January 3, 2023, billed with codes 87500, 87641, 87798, G0452, 87471, 
87481, 87551, 87651 and 87653.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC), patient weight 
capacity up to and including 300 pounds (K0823). 
 
You asked the Plan to pre-approve the Group 2 power wheelchair. You say that the enrollee would greatly 
benefit from the use of a power wheelchair to help with daily activities. You say that without the use of a 
power chair, the enrollee could be confined to a chair where they would not be able to do any activities of daily 
living (ADLs). The Plan denied your request. The Plan says the records do not support that the enrollee 
requires the requested power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiarys weight is less than or equal to 
the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight 
capacity of the next lower weight class PWC. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC), patient weight capacity up to and including 300 
pounds (K0823).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service December 15, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the bill type is correct. The Plan denied your 
request. The Plan says the claim was billed with an invalid type of bill. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was not billed with a valid type of bill code. 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 home health care billed for date of service 
December 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says 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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the required 
drug bevacizumab. Also, there is no documentation provided indicating that the Plan's required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lurpon depot. 
 You asked the Plan to pre-approve Lurpon depot. 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 Lurpon depot. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of advanced prostate cancer. The documentation does not support 
that the enrollee has tried and failed Eligard. The documentation does not support that Eligard 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 Lurpon depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lurpon depot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ear wax removal provided on March 
13, 2023. 
 
You asked the Plan to reduce the copayment for the ear wax removal. You say that you did not receive surgery 
services at a hospital. 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 $250 
copayment for in-network outpatient surgery, including services provided at hospital. 
 
You have been asked to pay a $250 copayment for the ear wax removal. This item/service falls within the in-
network outpatient surgery, including services provided at hospital 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. However, since the allowed amount is less than the 
standard copayment, you only owe $23.86. Therefore, we decided that the Plan does not have to reduce the 
copayment for the ear wax removal provided on March 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425x2, A0427x2) provided on 
December 1, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
are supported in the medical records. 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 providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the primary diagnosis reported on this claim is 
J12.82 (pneumonia due to coronavirus disease 2019). Diagnosis code J12.82 has a "code first" note, instructing 
providers to report code U07.1 (COVID-19) before sequencing/reporting code J12.82. This means that it is not 
appropriate to use diagnosis code J12.82 as the primary diagnosis. Therefore, we decided that the Plan does not 
have to pay for ambulance services (A0425x2, A0427x2) provided on December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued negative pressure wound therapy (NPWT). 
 
You asked the Plan to 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 continued NPWT is 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 approve these services. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has a sacral wound with bone 
exposure. The NPWT was started on April 26, 2023 and she was evaluated on May 30, 2023 for wound 
assessment and debridement. The records show that the wound size increased with the first month of NPWT 
and improved while the treatment was suspended. The criteria for coverage are not met and continued services 
are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to approve continued negative pressure wound therapy (NPWT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 5, 2023, billed with codes 
87798, 87653, 87651, 87641, 87500, 87481, and G0452. 
 
You asked the Plan to pay for the testing billed. You say that you disagree with the Plan's denial. 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 a panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
 
 We looked at the file and Medicare rules. This was a 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 testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on January 5, 2023, 
billed with codes 87798, 87653, 87651, 87641, 87500, 87481, and G0452.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Bicera (Wiltromm) Allograft during spine 
surgery. 
 
You asked the Plan to pre-approve the use of Bicera (Wiltromm) Allograft. You say that you need surgery due 
to long-term pain. You say that if you just get one part of the surgery, you would still be in pain. The Plan 
denied your request. The Plan says the use of Bicera (Wiltromm) Allograft is not proven. This is a ceramic-
based product, and there is insufficient literature to show that this product is superior to other allograft 
products. 
 
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 use of Bicera (Wiltromm) Allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Bicera Allograft is considered experimental at this time. More research 
is needed before this can be considered medically necessary and appropriate. 
 
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 use of Bicera (Wiltromm) Allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the use of Bicera (Wiltromm) Allograft during spine 
surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 14, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no coverage for CPT codes 0012M and 
0013M for CxBladder.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare coverage rules 
have not been met. Specifically, the service at issue is explicitly non-covered. Therefore, we decided that the 
Plan does not have to pay for CxBladder testing (0012M) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and J1561 for date of service 
April 6, 2022. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and J1561. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, and J1561 are not supported in the medical record. Specifically, 
medication administration record with required Name, Route, Dose, and start/stop times for the infusion 
services of Gamunex-C was not present in submitted medical records for the billed date of service. In addition, 
the time-based codes do not have a clear and valid start and stop time documented. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 96365, 96366, and J1561 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and J1561 for date 
of service April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs rehabilitative care to improve 
their functional independence. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee can get the care they need at 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cefaly nerve stimulator device. 
 
You asked the Plan to pre-approve a Cefaly device. You say that you have daily headaches along with 3 or 
more migraines per week. You say that you have had these symptoms for more than five years. You also say 
that you have tried Botox and many different medications with no good results. The Plan denied your request. 
The Plan says the requested device is not medically reasonable or necessary. 
 "The Plan follows Medicare rules. Medicare rules say that conditions for which TENS therapy is not 
considered to be reasonable and necessary include headache, visceral abdominal pain, pelvic pain, and 
temporomandibular joint pain. 
 
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 Cefaly device. Our reviewer says that 
a Cefaly device is not medically necessary. Our physician reviewer found the provided documentation indicates 
that this device is being requested to treat headaches. The reviewer also found that this device is not covered 
for this indicate. Therefore, the reviewer found that the Cefaly device 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 a Cefaly device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cefaly nerve stimulator device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from August 17, 2022, to September 8, 2022.  
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this is a medical necessity 
appeal based on medical literature and the efficacy of the treatment rendered. The Plan denied your request. 
The Plan says the denial of a water circulating heat pad with pump was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from August 17, 2022, to 
September 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa a self-administered drug. 
 
You asked the Plan to pre-approve Gemtesa. You say that the service is medically necessary. 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 Gemtesa a self-
administered drug.  
 
Benefits for Gemtesa 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 pay for orthotics provided on August 19, 2022. 
 
You asked the Plan to pay for orthotics. You say that you are requesting the submitted documentation be 
reviewed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for orthotics provided on 
August 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the phenylep ketorolac injection provided 
on January 23, 2023. 
 
You asked the Plan to waive the coinsurance for the phenylep ketorolac injection. You say that this should be 
included in the surgery. 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the phenylep ketorolac injection. This item/service falls 
within the in-network Medicare Part B drugs 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. The record shows this claim was approved and you are responsible for the 
cost share amount. The total you owe is $77.58 ($387.88 allowed amount  x 20% coinsurance = $77.58). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the phenylep ketorolac injection 
provided on January 23, 2023.