Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that that the step therapy requirements were not met.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Prolia. Our Medical Director states that the documentation does support that an injectable bisphosphonate would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition meets step therapy criteria for Prolia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia for the enrollee. 

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and an electronic 
connection device (E2311). 
 
You asked the Plan to pre-approve an expandable controller and an electronic connection device. You say that 
you are requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says 
these items are 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 an expandable controller and an 
electronic connection device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee has adequate strength to 
manage the standard power drive controls. The requested electronics are not necessary to meet the enrollee's 
needs.  
 
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 expandable controller and an electronic connection device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) and an 
electronic connection device (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the laboratory testing provided on November 3, 2022, billed 
with codes 87652, 87899, and 87900. 
 
You asked the Plan to pay for  the testing. You say that the billed codes are covered and medically necessary. 
The Plan denied your request. The Plan says the codes are not supported. 
 
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 codes 87652, 87899, and 87900 are as follows: 
 
87652 - Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 
 
87899 - Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; not 
otherwise specified 
 
87900 - Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the testing. Our reviewer says that the criteria for coverage 
has not been met. Our reviewer found, for CPT 87652, the procedure report describes Streptococcus group A, 
amplified probe technique. There is a more appropriate code to report for service provided. CPT 87652 is not 
documented in laboratory report, and therefore, cannot be verified. For CPT 87899, the procedure report does 
not include documentation of infectious agent antigen detection by immunoassay with direct optical (i.e., 
visual) observation. For CPT 87899, the lab analyst performs the technical lab test to analyze for an infectious 
agent by immunoassay with direct optical, meaning visual, observation. This procedure was not documented in 
laboratory report, and therefore, cannot be verified. For CPT 87900, the laboratory report does not include 
documentation of quantitative prediction of drug susceptibility phenotype, and therefore, cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for  the laboratory testing provided on November 3, 2022, billed with codes 87652, 87899, and 87900.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve a third level of MBBs. You say that the third level MBB is medically 
necessary.  The Plan denied your request. The Plan says the third level MBB 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 a third level of MBBs. Our reviewer 
says that the third level MBB is not medically necessary.  Our physician reviewer found the LCD utilization 
limit is to two levels of diagnostic MBBs per session. There is no documentation as to why a third level is 
required by extraordinary issues. Therefore, the third level is considered 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 a third level of MBBs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a third level of medial branch blocks (MBBs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, 83550, and 83970) 
related to end-stage renal disease (ESRD) provided on January 3, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (82728, 83540, 83550, and 83970) related to end-stage renal 
disease (ESRD) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided on March 3, 2023. 
 
You asked the Plan to pay for the massage therapy. You say that it is medically necessary. The Plan denied 
your request. The Plan says the Plan has limited chiropractic benefits and these services are excluded. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for massage therapy provided on March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious disease panel billed with 5 units of code 87481, 
2 units of 87801, and 13 units of 87798 on December 8, 2022 
 
You asked the Plan to pay for an infectious disease panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 

We looked at the file and Medicare rules. The panel at issue was billed with multiple codes. Based on this 
information, we decided that Medicare rules for coverage of an infectious disease panel have not been met. 
Therefore, we decided that the Plan does not have to pay for an infectious disease panel billed with 5 units of 
code 87481, 2 units of 87801, and 13 units of 87798 on December 8, 2022
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four skilled physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that all six physical therapy visits are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the four denied physical therapy visits meet Medicare 
criteria for approval. The latest provided records in this case are from January 20, 2023; no more current 
medical notes from the enrollee's treating physician or therapist are provided documenting an order or need for 
additional skilled physical therapy services. Records do not support that the complexity of the enrollees 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollees symptoms or functional status beyond the treatments already provided plus the two additional visits 
just approved 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four skilled physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspiration (20939).  
 
You asked the Plan to pre-approve the service. You say that the enrollee is experiencing extreme, debilitating 
pain. You say that the enrollee is unable to complete independent activities of daily life. You also say that the 
enrollee has severe foraminal stenosis.  The Plan denied your request. The Plan says the requested service is 
considered experimental/investigational.  
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested bone marrow aspiration (20939) is not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone marrow aspiration (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric foldable wheelchair.

You asked the Plan to pre-approve an electric foldable wheelchair. You say that you have a wedding to go to in August. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an electric foldable wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration (20939) and the Medtronic 
master graft allograft (20930).  
 
You asked the Plan to pre-approve the services. You say that the enrollee has severe pain which radiates down 
the outside of the right left and ankle. You say that the enrollee has had to alter their daily activities due to the 
pain and inability to walk or stand. You also say that the enrollee uses a wheelchair.  The Plan denied your 
request. The Plan says the requested services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Medtronic master graft allograft (20930) is not medically 
reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspiration (20939) and the Medtronic master graft allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy procedure provided on September 26, 2022, by an
OON provider. 

You asked the Plan to pay for the laparoscopy procedure. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized.

Medicare rules say that plans scan 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 no a network provider with the Plan. The Plan had network providers available
who could have provided the item/service at issue. We found no exception that would require the Plan to pay for the 
item/service. Therefore, we decided that the Plan does not have to pay for the laparoscopy procedure provided on 
September 26, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that after three months of healing 
you need to be fitted for a complete denture. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 14, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72040, 70100, 70310, 74240, and 74230 for 
date of service February 7, 2023. 
 
You asked the Plan to pay for procedure codes 72040, 70100, 70310, 74240, and 74230. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 72040, 70100, 70310, 74240, and 74230 are not payable as billed. Specifically, these 
services were billed with place of service 11 (office); however, the documentation shows that the services were 
provided in a mobile setting at a skilled nursing facility. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 72040, 70100, 70310, 74240, and 74230 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 72040, 70100, 70310, 74240, and 74230 for 
date of service February 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft substitute. 
 
You asked the Plan to pre-approve bone graft substitute. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 bone graft substitute. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of multilevel cervical spondylosis with radiculopathy at C5-
6 and C6-7 with a C7-T1 disc herniation to the right. Bone graft substitute and enhanced allograft products are experimental in cervical spine surgery. Iliac crest bone graft is the gold standard. Therefore, the enrollee does 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone graft substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone graft substitute.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute IRF admission and services. 
 
You asked the Plan to pre-approve continued IRF care. You say that the medical records support the need for 
IRF admission. The Plan denied your request. The Plan says Medicare criteria has not been met for continued 
IRF 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 continued IRF care. Our reviewer says 
that the requested IRF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee was admitted for lung transplant surgery. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support a need for 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 the enrollee 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 continued IRF care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous device. 
 
You asked the Plan to pre-approve interspinous device. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 interspinous device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has lumbar radiculopathy. There is no lumbar instability on flexion-
extension views demonstrated. Interspinous devices are experimental. Therefore, the enrollee does not meet 
criteria for the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interspinous device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve interspinous device.