Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a POGO automatic blood glucose device. 
 
You asked the Plan to pre-approve a POGO automatic blood glucose device. You say that you will only use the 
requested item. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a POGO automatic blood glucose device. Therefore, we decided that the Plan does not have to pre-approve 
a POGO automatic blood glucose device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support 
that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine panel testing provided on March 16, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel is a single test with multiple components 
and is characterized by a single unit of service. A panel cannot be unbundled and billed as individual 
components.  
 
We looked at the file and Medicare rules. The panel in this case was billed with multiple codes and not one unit 
of one code as required by LCA A58710. 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 
urine panel testing provided on March 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
established defining criteria for an appropriate Long Term Acute Care Hospital admission. The Plan denied 
your request. The Plan says the enrollee does not meet all the requirements; care is being provided in the 
current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Life2000 (E0466). 
 
You asked the Plan to pre-approve Life2000. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 Life2000. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary 
disease (COPD) and chronic respiratory failure and has been compliant and treated with Life2000 ventilator 
since 2/2021.To withdrawal this beneficial therapy from the enrollee would be substandard of care as it is 
currently treating the enrollee. Hence, continued home ventilation would be best practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Life2000 have been met. Therefore, we decided that the Plan has to pre-approve 
Life2000 (E0466).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74250 billed for date of service January 12, 
2023.  
 
You asked the Plan to pay for procedure code 74250. You say that this code should not be bundled. The Plan 
denied your request. The Plan says payment for code 74250 is bundled into payment for code 74240. 
 
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 74250 
is a column II code to column I code 74240 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 74250 billed for date of service January 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 You asked the Plan to pre-approve Orencia. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Enbrel, Humira, Kevzara, Rinvoq, Xeljanz, or Xeljanz XR is required 
before Orencia can be considered. 
 
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 Orencia. Our reviewer says that 
Orencia is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says the use of this drug/regimen is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Imfinzi. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found that the requested use of Imfinzi is not FDA 
approved for the enrollee's diagnosis. The requested use of Imfinzi is not indicated for patients who have 
progressed on chemotherapy and radiation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Magnetic Resonance Imaging, any joint of lower extremity 
(73721). 
 
You asked the Plan to pre-approve an MRI. You say that you are in severe pain you need an MRI on your right 
leg as soon as possible. The Plan denied your request. The Plan says that your medical records do not show you 
need an MRI, the criteria has not been met for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that you 
need this medical item. Our physician reviewer found during last encounter a right knee joint effusion was 
noted. You have had cortisone injection and these 2 factors amount to red flags and provide indication for the 
requested MRI of the right knee approval. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a Magnetic Resonance Imaging, any joint of lower extremity (73721).  
 
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not meet all the requirements. The Plan 
says that the services needed may be provided safely in 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need rehabilitation, it is not safe to go home 
alone. You need help getting around and needs to be turned every two hours, so you don't get ulcers, you have 
bladder issues and you are at risk of falls. The Plan denied your request. The Plan says your record does not 
show that you require daily skilled nursing or skilled therapy in a SNF setting. The Plan says that the services 
needed are called custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures involving arteries of upper leg, 
including bypass graft; not otherwise specified (01270) provided on May 2, 2023. 
 
You asked the Plan to pay for anesthesia. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says there is a list of recognized modifiers for 
anesthesia services. Modifier 78 is not listed. 
 
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 01270 is not supported in the medical record. Specifically, it is not appropriate to bill 
modifier 78 with anesthesia CPT code 01270. Based on this information, we decided that Medicare rules for 
coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified 
(01270) provided on May 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow. 
 
You asked the Plan to pre-approve an orthopedic pillow. You say that the requested item is a necessity for your 
care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that fabric supports are not covered 
because they are nonreusable and not rental-type items. 
 
While an orthopedic pillow may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve an orthopedic pillow.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87653, 87640, 87481, 87641, and 
87150 billed for date of service February 9, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87653, 87640, 87481, 87641, and 87150. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
payment for codes 87798, 87653, 87640, 87481, and 87641 is bundled into payment for code 87150. 
Additionally, payment for code 87150 is bundled into payment for code 87500. 
 
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 codes 
87798, 87653, 87640, 87481, and 87641 are column II codes to column I code 87150. Additionally, we have 
confirmed that code 87150 is a column II code to column I code 87500. The records do not support the billing 
of modifier 59 to bypass these edits. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87653, 87640, 87481, 
87641, and 87150 billed for date of service February 9, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services coded as 80048 and 84466 provided December 
3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says that the documentation 
submitted did not include a valid physician order therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies.  
 
We looked at the file and Medicare rules. The Plan has not substantiated their reason to continue to deny the 
laboratory services as the documentation submitted does include a valid laboratory requisition order form with 
a signature from the persons responsible for the care of the beneficiary for the laboratory services provided. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have been 
met. Therefore, we decided that the Plan has to pay for the laboratory services coded as 80048 and 84466 
provided December 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test, 22 or more drug classes (G0483) 
provided September 26, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says if a laboratory bills for a diagnostic laboratory test and documentation to support the medical necessity of the test is not submitted, then 
the claim is denied. 
 
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 laboratory service have been met. 
Additional records were requested from the provider. The records show the Plan made multiple requests to 
obtain the needed medical records without success. Therefore, we decided that the Plan does not have to pay 
for the definitive drug test, 22 or more drug classes (G0483) provided September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L2 kyphoplasty (22514, C1062).  
You asked the Plan to pre-approve L2 kyphoplasty. 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 follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 L2 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no trial of a back brace for 
fracture 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 L2 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L2 kyphoplasty (22514, C1062).