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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 12, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed testing is not 
covered. 
 
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. Review of the file shows that the billed unique identifier, ZB42N, is 
not covered for the billed testing (81479). Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested bed will help the 
enrollee, not the staff of your group home. The enrollee does not use a slide board,but needs a grab bar to assist 
her getting into and out of the bed. The Plan denied your request. The Plan says total electric hospital beds are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says imaging requires six weeks of provider directed treatment to be completed. 
This must have been completed in the past three months without improved symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found that you have chronic low back pain. The 
record provided does not document the presence of red flag signs or symptoms to mandate immediate MRI. 
The record does not indicate that a trial of conservative therapy has been tried and failed. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injection. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
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 Ozempic injection.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral to dermatology. 
 You asked the Plan to pre-approve the referral. You say that you have been with these doctors for a long time. 
The Plan denied your request. The Plan says the guidelines for out-of-network care have not been met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found that the enrollee is 
not receiving any active treatment and/or medical management of their condition that makes it medically 
necessary for this enrollee to continue care with the out-of-network dermatology as requested. There is nothing 
unique about the enrollee's condition that would make it medically necessary to continue care with this 
provider. The plan has providers who have the qualifications and expertise necessary to meet the current 
medical standards of care required for treatment of the enrollee's condition. The enrollee's medical management 
and/or follow-up care be safely transitioned to an in-network dermatology specialist at this time. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral to dermatology.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf Panel (81479) provided on April 13, 2023. 
 
You asked the Plan to pay for the OmniGraf Panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the OmniGraf Panel in the setting of 
kidney transplants have not been demonstrated in the peer-reviewed literature 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the OmniGraf Panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a literature search was completed reviewing evidence to support this test in the setting of 
kidney transplant patient after organ transplant surgery, and there are insufficient high-quality studies to 
support its use at this time. It was not clear from the studies whether or not testing would lead to improved 
outcomes long term. Therefore, it will be considered not medically necessary at this time.  
 
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 Panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the OmniGraf Panel (81479) provided on April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that you recommend this device for 
the enrollee's worsening heart failure. This device will allow you to better monitor and manage their symptoms 
that led to repeat heart failure hospitalizations. The Plan denied your request. The Plan says this procedure is 
not supported by research and is not covered. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the CardioMEMS System is considered experimental/investigational 
and is not medically necessary for the treatment of congestive heart failure.  
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this is needed to reduce the enrollee's symptoms and 
impact on quality of life. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Entyvio. Our reviewer says that the 
enrollee does not meet criteria for Entyvio. Our physician reviewer found Entyvio is not Food & Drug 
Administration (FDA) approved for microscopic colitis. This use is not supported by robust clinical research or 
major drug 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Entyvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and seat elevator. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee has outgrown their manual wheelchair of three years. You say that the recommended power chair has 
tilt to allow the enrollee to lay down and prevent sores. You also say that the lift will be helpful as a Hoyer lift 
is needed but never available. The Plan denied your request. The Plan says the requested Group 3 power 
wheelchair with multiple power options is not appropriate for the enrollee. The Plan also says that the enrollee 
should be checked to see if they can use the requested equipment. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when the criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options and set elevator are not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing power drive. The reviewer also found that the enrollee does not 
require a seat elevator to transfer or access higher objects or shelves. Therefore, the reviewer found that the 
requested Group 3 power wheelchair with multiple power options and seat elevator are 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 Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and seat elevator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x3) and home 
health skilled nursing (G0299 x2). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesnt support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 pre-approve home health physical therapy (G0151 x3) and home health skilled nursing 
(G0299 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral pathology services (D0473) provided on September 26, 
2023. 
 
You asked the Plan to pay for oral pathology services. You say that you would like to be reimbursed for this 
medically necessary service. You previously had a similar service done by a different physician, and that 
service was paid at that time. The Plan denied your request. The Plan says this provider in this case has opted-
out of Medicare; therefore, no Medicare payment may be made for any services rendered by this provider. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for oral 
pathology services (D0473) provided on September 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) for each quadrant. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services do not meet the criteria for coverage. 
 
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 
services 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 services. Our physician 
reviewer found the Plan allows for scaling and root planing when medically necessary. In this instance there is 
insufficient support for the use of code D4341 which is reserved for when four or more teeth are periodontally 
involved including the visual loss of bone indicating loss of clinical attachment. In this instance, as there are 
less than four involved teeth in any quadrant as noted by the lack of bone loss except around teeth #2 and #19.  Where there are less than four involved teeth in a quadrant, another code is available if the criteria of loss 
of attachment and abnormal pocketing is met. In this instance, there is no support for the requested four 
quadrants of scaling and root planing. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341) for each 
quadrant.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the retroperitoneal ultrasound (76770) 
provided on August 9, 2023. 
 
You asked the Plan to waive the cost share for the diagnostic service. You say that you were asked to pay a $20 
copayment. You say that you received a bill for an additional $88.87. You also say that your diagnostic tests 
have always been covered. 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 $120 
copayment for outpatient diagnostic test and therapeutic services.  
 You have been asked to pay a $108.87 copayment for the diagnostic service. This service falls within the 
outpatient diagnostic test and therapeutic services 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 
cost share for the retroperitoneal ultrasound (76770) provided on August 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery 
only, through separate skin or fascial incision (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that you disagree with the denial and 
would like the bone marrow aspirate approved. The Plan denied your request. The Plan says the medical 
necessity for the denied procedure has not been established after clinical review and per the peer-reviewed 
medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental and investigational for use as a bone graft. The 
enrollee does not meet criteria for approval of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate 
skin or fascial incision (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 15, 2023, billed 
with procedure code 00140-QZ-QS-P2 (55 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says a corrected claim must be submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
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 the practitioner services provided have 
been met. Specifically, a corrected claim must be submitted to reprocess the claim. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 15, 2023, billed with procedure code 
00140-QZ-QS-P2 (55 units).