Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 You asked the Plan to pre-approve Retacrit. 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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Aranesp or Procrit. The documentation does not support that Aranesp or 
Procrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (head and foot adjustment), 
with any type of side rails, with mattress (E0260) and bed side rails (E0305). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and bed side rails. You say that the enrollee 
needs the requested bed. The Plan denied your request. The Plan says the records do not show you meet the 
Medicare criteria for approval of the requested hospital bed. The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed and bed 
side rails. Our reviewer says that the service is not medically necessary. Our physician reviewer found you are 
noted to have impaired mobility and neck and low back pain. However, you can ambulate with the assistance 
of a rollator and there is no documentation indicating that you have impairment with regards to performing 
weight shifts or pressure relief while in bed. There is no indication that you require elevation of the bed greater 
than 30 due to dyspnea. The documentation does not indicate that you are unable to re-position yourself while 
in bed and require frequent re-positioning or an immediate change in position, which is required for a semi-
electric hospital bed. There is also no documentation indicating that that you have tried other positioning 
modalities, including pillows or wedges with a standard bed. Therefore, the requested semi-electric hospital 
bed and bed side rails are 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 a semi-electric hospital bed and bed side rails have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a semi-electric hospital bed (head and foot adjustment), with 
any type of side rails, with mattress (E0260) and bed side rails (E0305).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 27, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that this should be covered due to medical necessity. 
The Plan denied your request. The Plan says this service was provided OON without the required authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care services provided on September 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation to dialysis appointments. The Plan denied your request. The Plan says you have exhausted your 
routine transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) 
device (E0601). 
 
You asked the Plan to pre-approve continued CPAP device. You say that the CPAP device is medically 
necessary due to obstructive sleep apnea. The Plan denied your request. The Plan says you do not meet criteria 
for a continued CPAP device. 
 
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 continued CPAP device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the CPAP at 
issue in this case meets all of Medicare's LCD criteria for medically reasonable and necessary for you. 
Provided records in this case do not document an in-person clinical re-evaluation by the treating practitioner 
with documentation that symptoms of obstructive sleep apnea are improved, as required by the LCD. Provided 
records document a telemedicine visit and do not include a qualifying sleep study report. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued CPAP device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the abdominal ultrasound (76705-26) provided on September 9, 2022. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this provider is not eligible for 
payment for the professional component of this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support why the 
provider at issue is not eligible to be paid for the professional component of the service at issue. It is the burden 
of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for the abdominal 
ultrasound (76705-26) provided on September 9, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that this is medically necessary. The 
Plan denied your request. The Plan says the service at issue is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A non-spinal electrical osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve A non-spinal electrical osteogenesis stimulator. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator will be 
denied as not medically necessary if none of 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 non-spinal electrical osteogenesis 
stimulator. Our reviewer says that the service is not medically necessary. Our physician reviewer found a total 
of 9 months have not passed since the patient's foot fusion surgery. More time is needed to show nonunion. 
 
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 non-spinal electrical osteogenesis stimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve A non-spinal electrical osteogenesis stimulator (E0747).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sleep study (95810). 
 
You asked the Plan to pre-approve a repeat sleep study. You say that you need this sleep study to determine if 
you need a new CPAP, or what is going on. You also say that you are still having trouble sleeping, and the 
doctor wants to update your test because it has been around 10 years since you have had one. The Plan denied 
your request. The Plan says this service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography studies may be indicated 
for the conditions listed in the Medicare rules section of this letter. 
 
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 repeat sleep study. Our reviewer says 
that an attended diagnostic polysomnogram is not medically necessary. Our physician reviewer found there are 
no clinical notes documenting your current use or tolerance of CPAP. There is no device download 
documenting compliance and effectiveness of treatment. Our reviewer found there is no documentation of a 
substantial change in your weight or health status. Our physician reviewer also found that a repeat sleep study 
is not necessary in order to replace a device that is no longer functional, and the medical records do not support 
the need for a repeat sleep study. 
 
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 repeat sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sleep study (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the out-of-network consultation, contact lens fitting, and 
contact lenses. 
 
You asked the Plan to pre-approve the consultation, contact lens fitting, and contact lenses. You say that you 
have tried other places to get contact lenses and the lenses do not fit properly. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the requested provider is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the consultation, contact lens fitting, and contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve the out-of-network 
consultation, contact lens fitting, and contact lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the smart vest will provide the enrollee effective 
airway clearance she needs. This device will prevent future hospital admissions. The Plan denied your request. 
The Plan says records do not show that the enrollee has a diagnosis of a cystic fibrosis, neuromuscular disorder, 
or bronchiectasis. Under Medicare, the request is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Provided records in this case do not 
document a diagnosis of cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high 
frequency chest wall oscillation device may be covered. The enrollee does not presently use a mechanical in-
exsufflation device (E0482) and plans to continue to do so. Provided records in this case do not show well-
documented failure of standard treatments to adequately mobilize retained secretions. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service December 6, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
 We find that CPT code 99214 is not supported in the medical record. Specifically, this code is included in the 
global surgical period for code 62323. The submitted documentation doesn't support a significant, separately 
identifiable evaluation and management service to support the use of the -25 modifier. Therefore, this code it 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99214 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99214 for date of service December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2022, billed 
with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 
81345, and 81272. 
 
You asked the Plan to pay for the genetic 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 2, 2022, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81209, 81314, 81334, 81345, and 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that the enrollee would benefit from the Cala 
Trio Device to treat his essential hand tremors. The enrollee wishes to avoid pharmacologic treatments. The 
Plan denied your request. The Plan says this is an experimental/investigational service and this item 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 a Cala Trio device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per the literature, the effectiveness of this device is not established for the treatment 
of essential and Parkinsonian tremor. Medical necessity has not been met 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 as the requested device is not proven to have long term effectiveness for the enrollee's condition. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018, K1019).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 78020 billed for date of service September 16, 2022. 
 
You asked the Plan to pay for code 78020. You say that code 78020 is not inclusive to any other code billed ot 
this date of service. The Plan denied your request. The Plan says you did not bill this service with an 
appropriate primary procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 78020 
is an add-on code.  While code 78020 was billed with a valid primary procedure code (78018), that primary 
procedure code was not payable because it was bundled with code 79005.  Because the primary procedure is 
not payable, the add-on procedure also cannot be paid.  Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for code 78020 billed for date of 
service September 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation for medically necessary surgery. The Plan denied your request. The Plan says this requested trip 
exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile limit.