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

 
We decided that the Plan does not have to pay for practitioner services provided on July 29, 2022, to August 2, 
2022. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
services. 
 
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, the submitted documentation did not include the actual date of service in which the 
services were rendered. The charted date, dictated date, transcribed date, signed date, admit date or discharge  
date are not sufficient and cannot be used to verify the date of service. The requested documentation has not 
been provided to verify the billed services. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on July 29, 2022, to August 2, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 You asked the Plan to pre-approve Ocrevus. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Ocrevus. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on June 14, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2023, billed 
with codes 87481, 87653, 87798 and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing at issue was medically 
necessary.  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 testing multiple pathogenic genes 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 February 16, 2023, billed with codes 87481, 87653, 87798 and 87801.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Breast Cancer Index (BCI) testing provided on May 3, 2023.  
 
You asked the Plan to pay for the BCI testing. You say that the correct DOS was reported for molecular 
pathology services.  The Plan denied your request. The Plan says that the DOS for lab testing must be the date 
the specimen was collected.  
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology testing such as the BCI 
testing should report the date the testing was performed as the DOS, unlike other lab tests.  
 
We looked at the file and Medicare rules. This testing meets the criteria to report the date testing was 
completed as the DOS. Based on this information, we decided that Medicare rules for coverage of the BCI 
testing have been met. Therefore, we decided that the Plan has to pay for the Breast Cancer Index (BCI) testing 
provided on May 3, 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: 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 cannot walk and need rehabilitation for your 
hips. The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an IRF.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic artery embolization. 
 
You asked the Plan to pre-approve prostatic artery embolization. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this procedure is unproven due to insufficient 
evidence of safety and efficacy. 
 
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 prostatic artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic artery embolization is considered an experimental technique to 
treat benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term efficacy 
and safety. This is not recommended outside of a clinical trial 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 prostatic artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostatic artery embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic footwear provided on March 31, 2023. 
 
You asked the Plan to pay for diabetic footwear. You say that this claim should be reconsidered for 
reimbursement. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the specific supplies provided in this case. The physician order submitted does not specify the diabetic footwear that was to be furnished to the enrollee. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for diabetic footwear provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0318 rendered on May 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 G0318 is not supported in the medical record. Specifically, no records were provided. 
Therefore, we are unable to verify if G0318 was a separate, unrelated service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0318 rendered on May 17, 2023.
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 want to gain back your independence. The Plan 
denied your request. The Plan says services can be continued at a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. You do not require treatment by multiple therapies. While the medical record supports a need for 
physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that denying authorization or 
downgrading to a lesser device would have devastating consequences for the enrollee. You say that while other 
devices can provide a similar mode called AVAPS, they are not equipped with the same pressure and flow 
ranges or features necessary for the enrollee needs of advanced ventilation. The Plan denied your request. The 
Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has obesity hypoventilation syndrome (OHS). The enrollee's recent admission shows improvement with BiPAP 
therapy. While there is no documented indication for a home ventilator, the enrollee will likely benefit from a 
BiPAP. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (95810). 
 You asked the Plan to pre-approve an attended polysomnography. You say that you cannot work the machine 
at home. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. Follow-up 
polysomnography studies may be indicated after a substantial weight change or when clinical response is 
insufficient or when symptoms return despite a good initial response to treatment with continuous positive 
airway pressure (CPAP). 
 
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 an attended polysomnography. Our 
reviewer says that the requested polysomnography is not medically necessary. Our physician reviewer found 
the most recent sleep evaluation on June 29, 2023, indicates that the patient got a new CPAP machine in 2021, 
but it is unclear whether the patient is currently using it. There is no major change in body weight or health 
status since the last sleep study. This patient's diagnosis of obstructive sleep apnea is not in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an attended polysomnography (95810).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that the requested drug is medically necessary. You 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that 
the criteria listed in the Food and Drug Administration (FDA) package label for Leqembi have not been met.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Leqembi. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found the enrollee is noted to have undergone 
cerebrospinal fluid (CSF) testing showing findings supportive of an Amyloid beta pathology. There were no 
other contraindications listed to the use of the drug (based on the prescribing label). In as much, this request 
would be 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 Leqembi have been met. Therefore, we decided that the Plan has to pre-approve 
Leqembi.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services. 
 
You asked the Plan to pre-approve PBRT services. You say that the enrollee would have a greater benefit from 
PBRT versus standard radiation. You say that PBRT is medically necessary and supported by the 
documentation provided.  The Plan denied your request. The Plan says there is no clear evidence that supports 
the benefit or decrement to proton therapy over Intensity-modulated radiation therapy (IMRT) for either 
treatment efficacy or long-term toxicity. The Plan says that PBRT is not the standard of care for prostate cancer 
and should only be performed within the context of a prospective clinical trial.  
 
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 PBRT services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation 
therapy, intensity modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
Recent data shows no significant differences in late (years one, two, and three) patient-reported toxicity 
outcomes between proton beam therapy and IMRT.  The most recent American Urological Association (AUA) 
and National Comprehensive Cancer Network (NCCN) guidelines state that PBRT offers no clinical advantage 
over other forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22612) and posterior non-segmental 
instrumentation (22840). 
 
You asked the Plan to pre-approve the Minuteman device. You say that the pain limits the enrollee's ability to 
participate in normal activities of daily living, and in turn, these limitations diminish their overall quality of 
life. The Plan denied your request. The Plan says the 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 the Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Minuteman device is experimental and more research is needed. 
 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis (22612) and posterior non-segmental instrumentation (22840).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on November 23, 2022, billed 
with codes 87481, 87798 and 87653. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this test was necessary and is supported 
in the medical record. 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 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on November 23, 2022, billed with codes 87481, 87798 and 87653.