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 August 27, 2022, billed with 
codes 0031U, 0032U, 0033U, 81230, 81231, 81232, 81306, 81335, 81355, 81291, 81407 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 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 
August 27, 2022, billed with codes 0031U, 0032U, 0033U, 81230, 81231, 81232, 81306, 81335, 81355, 81291, 
81407 and 81238.
Appeal type: Drugs
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Retacrit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital treatment from May 19, 
2023-forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital treatment. 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. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital treatment. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon 
review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of May 19, 2023, forward and could have been treated in a 
lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, or delusions. He was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety as the enrollee awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient psychiatric hospital treatment from May 19, 2023-
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says it is not 
necessary to control power options through a 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 the requested items. Our physician 
reviewer found that you have left side hemiparesis and 4 out of 5 strength on the right side. The records show 
that you have adequate upper extremity strength and range of motion to manage standard power drive controls. 
Therefore, the request 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 the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an expandable control system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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. 
 
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. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has 
chronic obstructive pulmonary disease (COPD) and was recently hospitalized with pneumonia and acute 
exacerbation of COPD. Arterial blood gas (ABG) during the hospitalization was consistent with mild acute on 
chronic hypercarbic respiratory failure. There are no pulmonary function tests to confirm airways obstruction 
or assess severity, although the chest x-ray showed emphysematous changes. There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. There is no ABG done while stable to document chronic CO2 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with 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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for 
December 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. 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 pay for the subsequent 
hospital care billed with code 99232 for December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections-bilateral to knees. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that platelet rich plasma injections 
are medically necessary. The Plan denied your request. The Plan says platelet rich plasma injections do not 
meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 platelet rich plasma injections. Our 
reviewer says that the requested platelet rich plasma injections are not considered medically necessary. Our 
physician reviewer found evidence is still limited due to the overall high risk of bias in previous trials and great 
variability between studies regarding the number of injections (generally 1 to 4), the interval between 
injections, preparation of the PRP, and volume injected. Furthermore, the typical length of follow up was only 
one year or less. There is also uncertainty regarding whether individuals with less severe OA may benefit more 
from this intervention compared with individuals with more advanced structural damage. Additionally, it is 
unclear whether LR-PRP or LP-PRP should be utilized (though the latter appears to have an advantage.) 
Larger controlled studies comparing PRP with placebo and alternatives other than HA are needed to determine 
the efficacy of PRP for knee OA. Further studies are also needed to determine the optimal protocol for delivering PRP. At present, the evidence is insufficient to determine the effects of PRP on health outcomes for 
OA. You were being treated for bilateral primary osteoarthritis of the knees. You presented with bilateral knee 
pain. You state they are still quite a bit better than before you had stem cells, but you are wondering about PRP. 
The exam reveals positive medial joint line pain bilaterally. There is no instability in the knee. However, 
detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. Moreover, as per the LCD, there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. No compelling rationale is presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested platelet-rich plasma injections to the bilateral 
knees, do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet rich plasma injections-bilateral to knees.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospital admission. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric hospital admission. The Plan denied your 
request. The Plan says this request for psychiatric inpatient hospital level of care for this admission is not 
medically necessary as of May 21, 2023. The Plan also says the service needed can be provided safely in other 
settings. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric 
hospital admission. Our reviewer says that the enrollee does not meet the Medicare criteria for continued 
inpatient psychiatric care. Our physician reviewer found it is not expected this enrollee will improve in a 
reasonable period of time as they do not have suicidal or homicidal ideation, auditory or visual hallucinations. 
The enrollee was compliant with treatment while not showing any acute threats to safety. Our reviewer also 
found that it does not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than 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 a continued inpatient psychiatric hospital admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospital 
admission.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on January 29, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on January 29, 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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
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 enrollee is non-weight bearing and unable to benefit from intensive rehabilitation. 
The enrollee's fatigue limits their capacity for intensive rehabilitation. The enrollee does not have a need for 
frequent physiatry oversight. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the SPRINT PNS system is 
medically necessary. The Plan denied your request. The Plan says the SPRINT PNS system 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 SPRINT PNS system. Our reviewer 
says that the requested SPRINT PNS system is not considered medically reasonable and necessary. Our 
physician reviewer found that the Sprint PNS is considered experimental/investigational for the treatment of 
low back pain and this indication is the subject of ongoing clinical trials. Therefore, the request is deemed not 
medically 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 the SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 10, 2023, to 
January 13, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct type of bill. 
 
The Plan follows Medicare rules. The rules say that for home health services must be billed with a valid type of 
bill. 
 
We reviewed the file and the Medicare rules. We find that a valid type of bill was not submitted on the claim. 
Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from January 
10, 2023, to January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater 
genes, Tempus xF (81455) provided January 2, 2023. 
 
You asked the Plan to pay for the Tempus xF. You say that denial of this claim based on failure to obtain prior 
authorization is not justifiable in this instance. The Plan denied your request. The Plan says the requested test is 
not reasonable and necessary because the enrollee does not have a recurrent, relapsed, refractory, metastatic, or 
advanced cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xF have not been met. Therefore, we decided that the Plan does not have to pay for the 
targeted genomic sequence analysis panel, 51 or greater genes, Tempus xF (81455) provided January 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. 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 Xgeva. 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Joerns Portable Go ceiling lift. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the enrollee would not be able to use a Medicare-approved 
ceiling lift. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 lift. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation indicates that you require a mechanical lift for transfers, but there is 
no clear indication that a specific brand of patient lift or one that is attached to the ceiling is required. 
 
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 lift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Joerns Portable Go ceiling lift.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for September 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 14, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
September 7, 2022.