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 December 23, 2022. 
 
You asked the Plan to pay for the genetic testing billed. 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 
December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation with a pulmonologist to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON pulmonology consultation. You say that this is the only 
pulmonologist that can help you with your condition. The Plan denied your request. The Plan says there is no 
evidence that an in-network pulmonary specialist cannot provide the services you require.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. Though you state that this OON provider is 
the only one who can help, no information to support this is in evidence. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve consultation with a pulmonologist to be provided by an out-of-network (OON) provider.
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 a home ventilator is medically necessary. 
The Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient 
because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS). The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient was treated with BIPAP with AVAPS and improved appropriately per 
the documentation and data provided. Hence, there is no indication for a home ventilator, as continuing BIPAP 
with AVAPS would be best practice for this patient at this time. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513). 
 You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered when specific 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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found Based on the 
medical records provided there is no documentation that the percutaneous vertebral augmentation at issue in 
this case meets all Medicare criteria for medically reasonable and necessary for the patient as stated in the LCD 
L34106. Provided records in this case do not document the fracture is acute (< 6 weeks) or subacute (6-12 
weeks) as required by the LCD. As of 08/15/2023 records report the condition had been going on for 2-6 
months and began suddenly after a fall. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ procedure. 
 
You asked the Plan to pre-approve LinQ. You say that the enrollee has sacroiliac joint pain and sacroiliitis. The 
Plan denied your request. The Plan says the clinical value and effectiveness of this procedure have not been 
demonstrated in this setting. 
 
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 LinQ. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found multiple other plausible pain generators including the lumbosacral spine are evident. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical 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 LinQ have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the LinQ procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Vertiflex Superion device. 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 compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Vertiflex 
Superion interspinous spacer at L4-5, in this case, 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 a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit on date of service June 28, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that the copayment for the office visit 
should be waived because the enrollee was charged for a specialist visit but was seen by a nurse practitioner. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $25 copayment for consultation, diagnosis, and treatment by a specialist or under certain 
circumstances, treatment by a nurse practitioner, physicians assistant, or other non-physician health care professional in a specialists office (as allowed by Medicare).  
 
The enrollee has been asked to pay a $25 copayment for the office visit. This item/service falls within the 
consultation, diagnosis, and treatment by a specialist or under certain circumstances, treatment by a nurse 
practitioner, physicians assistant, or other non-physician health care professional in a specialists office (as 
allowed by Medicare) benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
office visit on date of service June 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev.  
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ofev.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis and a CT scan of the 
abdomen chest. 
 
You asked the Plan to pre-approve the CT scans. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the requested CT scans are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scans. Our reviewer says that 
the requests are medically necessary. Our physician reviewer found that annual surveillance with CT of the 
chest, abdomen and pelvis is reasonable and there are prior scans which will serve as a comparison. The 
request is reasonable due to their abnormal labs and increased risk for multiple myeloma and/or lymphoma. 
 
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 CT scans have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the abdomen and pelvis and a CT scan of the abdomen chest.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you still continue to need home health 
services and you would like for them to continue at this time. 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 the 
documentation doesnt support that the enrollee requires additional skilled nursing services or skilled rehab 
services to provide treatment that is 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve HBOT. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that the request does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that HBOT may be covered under certain circumstances. 
 
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 HBOT. Our reviewer says that the 
enrollee does not meet the coverage indications for this procedure. Our physician reviewer found that there is 
insufficient supportive evidence for this treatment for the enrollee's condition to justify this request 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 HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport provided on July 6, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON ambulance transportation. You say that the ambulance trip was 
medically necessary in this case.  The Plan denied your request. The Plan says OON services that are not 
emergent require 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 non-emergent ambulance transport provided 
on July 6, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 71271 billed for date of service June 6, 
2023.  
You asked the Plan to pay for procedure code(s) 71271. You say that the services at issue were a necessity for 
the enrollee's care. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 71271. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 71271. Based on this information, 
we decided that Medicare rules for coverage of procedure code 71271 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 71271 billed for date of service June 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(tilt) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with tilt. You say that this is necessary for the 
enrollee to be able to perform MRADLs independently in the home. You say that the enrollee has a history of 
skin breakdown due to the inability to perform a functional weight shift. You also say that this is medically 
necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee has a 
neurological disease, myopathy, or congenital skeletal abnormality. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition;  
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 
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 Group 3 power wheelchair with tilt. 
Our reviewer says that the requested Group 3 power wheelchair with tilt is not medically necessary. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has a mobility 
limitation that is due to a neurological condition, myopathy, or congenital skeletal deformity. Therefore, the 
reviewer found that the requested Group 3 power wheelchair with tilt 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 a Group 3 power wheelchair with tilt have not been met. Specifically, the file 
does not support that the enrollee has a condition which supports the need for a Group 3 power wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option (tilt) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the enrollee needs to have the 
ILR due to having a cryptogenic stroke. The Plan denied your request. The Plan says that the enrollee does not 
meet requirements for this request to be medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on National 
Coverage Determination (NCD) criteria. Our physician reviewer found that the enrollee had no history of atrial 
fibrillation, nor were there any significant cardiac arrhythmias noted on EKG monitoring. A recent randomized 
clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with 
oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or 
systemic embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. 
At this time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
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 the services are medically necessary for you to 
continue receiving therapy services and regain your strength. The Plan denied your request. The Plan says you 
do not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 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.