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

 
We decided that the Plan does not have to pay for physician's services provided on May 27, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no 
good cause to make an exception to the 12-month timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until July 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression wrap, non-elastic, below knee 
(A6545) provided November 4, 2022. 
 
You asked the Plan to pay for the gradient compression wrap. You say that you request reconsideration and 
reprocessing of this claim. The Plan denied your request. The Plan says the diagnosis does not substantiate the 
service. 
 
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 gradient compression wrap have 
been met. Additional records were requested from the provider to determine how the enrollee came to the 
servicing provider, whether the services were performed as billed and w the services are medically necessary. 
The records show that the Plan made multiple attempts to obtain the needed records from the provider without 
success. Therefore, we decided that the Plan does not have to pay for the gradient compression wrap, non-
elastic, below knee (A6545) provided November 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Kerecis Omega3 Wound provided on May 16, 2023. 
 
You asked the Plan to pay for the Kerecis Omega3 Wound. You say that the Kerecis Omega3 Wound was 
medically necessary. The Plan denied your request. The Plan says that the requested Kerecis Omega3 Wound is 
experimental, investigational or unproven.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Kerecis Omega3 Wound. Our reviewer 
says that the requested Kerecis Omega3 Wound is considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Kerecis Omega3 Wound is medically necessary due to the location and 
based on the community standards 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 the Kerecis Omega3 Wound have been met. Therefore, we decided that the Plan 
has to pay for the Kerecis Omega3 Wound provided on May 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the EsoGuard testing (0114U) provided June 9, 2023. 
 
You asked the Plan to pay for  the laboratory testing. You say that you are appealing the denial for EsoGuard 
that was denied for prior authorization needed. The Plan denied your request. The Plan says screening for 
Barretts esophagus is not a covered screening service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per DEX Diagnostics Exchange Registry, the testing is considered 
non-covered after the Molecular Diagnostics Tests (MolDx) program evaluation. Based on this information, we 
decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided 
that the Plan does not have to pay for  the EsoGuard testing (0114U) provided June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) provided May 8, 2023 
 
You asked the Plan to pay for the laboratory testing. You say that you are requesting review of these 
documents and full allowance of the contracted or list price for Guardant Reveal against the enrollee's in-
network benefits The Plan denied your request. The Plan says this testing is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per DEX Diagnostics, Guardant Reveal is not covered by Medicare. 
Per NCCN Guidelines for Colon Cancer, Version 2.2023, there is insufficient data to recommend post-surgical ctDNA to estimate risk of recurrence or determine adjuvant therapy. Per Hayes, based on a review of full-text 
clinical practice guidelines and position statements, guidance appears to confer no/unclear support for the 
Guardant Reveal test due to inconsistency between guidelines. Per ClinicalTrials.gov, study with NCT 
04726800 is investigating the usefulness of measuring ctDNA to monitor for residual disease after surgery. 
Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been 
met. Therefore, we decided that the Plan does not have to pay for Guardant Reveal (81479) provided May 8, 
2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that you require tilt and recline as noted in 
your therapy evaluation. You also say that you are at a high level of skin breakdown due to lack of pressure 
relief capability. The Plan denied your request. The Plan says there is not a medical need to control these power 
options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the criteria for the requested expandable controller, harness and electronic accessory 
have not been met per LCA Policy Article A52504 and per Social Security Act, Section 1862 (a)1(A) and the 
42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
Your upper extremity strength and functional ability is shown as independent in feeding and set up for bathing 
and grooming support that you can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc/Synvisc-One. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, Euflexxa, Durolane, and/or Gelsyn. The records do not show that the required drugs 
would be contraindicated or less effective; therefore, Synvisc/Synvisc-One is not 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 pre-approve Synvisc/Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has nasal polyps. 
Budesonide is not approved by the Food and Drug Administration (FDA) for this condition. The use is not 
supported by one of the major drug compendia or clinical research appearing in a Medicare-approved medical 
journal. Budesonide is therefore 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 pre-approve Budesonide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) machine for your 
shoulder. 
 
You asked the Plan to pre-approve a CPM machine. You say that your doctor ordered this for your shoulder. 
The Plan denied your request. The Plan says this item is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion (CPM) machine for your shoulder.
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's medical condition requires daily, 
medically necessary oversight by a physician, continuous nursing, and an interdisciplinary approach to 
rehabilitation in order to return home and to their prior level of function, and to avoid readmission into the 
hospital. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines.  
 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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status. 
The member can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. You say that this is the best clinical option for the enrollee. The Plan 
denied your request. The Plan says the records show that the enrollee's chronic compression fracture at L1 has 
been present for more than 12 weeks. The Plan also says that the requested PVA 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 PVA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding an acute or subacute lumbar compression 
fracture at L1. Additionally, there is no documentation of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is an MRI corroboration of other plausible 
causes of pain. Therefore, the documentation does not support that the criteria for PVA (percutaneous vertebral 
augmentation) have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA Molecular Signature testing (81479) provided 
March 28, 2023. 
 You asked the Plan to pay for the laboratory testing. You say that you request reconsideration of the denial of 
coverage and payment for PrismRA testing. The Plan denied your request. The Plan says charges in connection 
with services or supplies considered to be experimental or investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical value and effectiveness of the PrismRA Molecular 
Signature test in the setting of rheumatoid arthritis have not been demonstrated in the peer-reviewed literature. 
Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the PrismRA Molecular Signature testing 
(81479) provided March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
April 28, 2022, billed with code 99214-25. 
 
You asked the Plan to pay for the EM services as billed. You say that this should be paid. The Plan denied your 
request. The Plan says payment for the EM services was correctly denied. 
 
The Plan follows Medicare rules. Medicare rules say that modifier "-25" is used to facilitate billing of 
evaluation and management services on the day of a procedure for which separate payment may be made. It is 
used to report a significant, separately identifiable evaluation and management service by same physician on 
the day of a procedure. 
 
We asked our coding 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 EM services as billed. Our reviewer says 
that the use of modifier 25 is not supported to allow separate payment in this case. Our physician reviewer 
found the medical record does not include documentation of a significant, separately identifiable evaluation and 
management (EM) service above and beyond that associated with the laryngoscopy procedure performed, and 
therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the evaluation and management (EM) services provided on April 28, 2022, billed 
with code 99214-25.
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 you require IRF services in order to return home at 
your maximum level of functioning. The Plan denied your request. The Plan says IRF care 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement. However, there is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. The 
enrollee can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
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 requires IRF services to regain their 
prior level of functioning and independence. The Plan denied your request. The Plan says IRF care 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, there is no 
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The enrollee can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.