Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says there is insufficient evidence that supports long-term 
improved health outcomes. The requested procedure is considered experimental and investigative and 
therefore, not covered by Medicare. 
 
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 Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic 
changes without facet degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary. The Plan denied your 
request. The Plan says a trial of an injectable bisphosphonate is required before Procrit 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 Procrit. Our reviewer says that Procrit 
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 for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2022, billed 
with codes 81210, 81235, 81275, 81404, and 81405. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 28, 2022, billed with codes 81210, 81235, 81275, 81404, and 81405.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the supply allowance for the CGM. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the coverage 
criteria for a CGM and the supply allowance requires insulin use or low blood sugar. The enrollee is no longer 
on medications that would cause low blood sugar as they are only taking Ozempic. Although a CGM might 
help the enrollee blood glucose control the criteria for coverage are not met 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 the supply allowance for the CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is needed for chronic back pain. The Plan 
denied your request. The Plan says Medicare does not cover experimental technology. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes without 
stenosis or facet joint degenerative disease. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on January 2, 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 services are not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that patient transportation from one hospital or SNF 
to another is included in the inpatient payment. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are an ambulance transport 
from one facility to another while the enrollee was inpatient. Payment for these services is included in the inpatient hospital payment. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on January 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral appliance rendered on January 17, 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 services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that claim lines billed without a GA, GZ, or KX modifier 
will be rejected as missing information. 
 
We looked at the file and Medicare rules. The file shows that code E0486 was not billed with the required GA, 
GZ, or KX modifier. Therefore, we decided that the Plan does not have to pay for the oral appliance rendered 
on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 25, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 29, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time services were provided the enrollee was 
residing in an assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on August 16, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that that the enrollee has pain aggravated by 
movement. The Plan denied your request. The Plan says that acupuncture was provided by an unqualified 
provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on 
August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on April 5, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
are appealing the denied claim. The Plan denied your request. The Plan says Tetanus, Diphtheria Toxoids and 
Acellular Pertussis vaccine is not eligible under the Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on April 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you say that you had surgery. You say that 
you need transportation to your appointments. You also say that it is hot in the summer and the air quality is 
not great. The Plan denied your request. The Plan says additional trips beyond what the benefit offers are not 
covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
rendered on February 9, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says these codes are not reimbursable as separate charges. 
 
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 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include documentation to support any of these codes or the reported modifier XU - unusual non-overlapping 
service. Therefore, these procedures are included in CPT 87801 and CPT 87500. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 rendered on February 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Botox have 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 Botox. Our reviewer says that treatment 
with Botox is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Dysport or Xeomin before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).  
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary to treat the enrollee.  The Plan denied your request. The Plan says ordering a multi-class 
panel of definitive (confirmation) urine drug tests that are not used in clinical 
management, exceeds the needs of the member. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in 
the rules section of this letter 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
medical record sent by the provider documents the condition of the enrollee is opioid dependence with 
medication assisted treatment using Buprenorphine. The enrollee is also taking Fioricet and nortriptyline. 
Definitive toxicology testing for only the following 11 drug classes are considered relevant to the treatment 
program: Buprenorphine; Fentanyls; Heroin metabolite (6-MAM); Methadone; Opiates;Opioids and Opiate 
analogs; Oxycodone; Tapentadol; Tramadol; Barbiturates; and Tricyclic Antidepressants. The Substance Abuse 
and Mental Health Services Administration (SAMHSA) recommends definitive urine drug testing for only 
relevant illicit drugs during opioid addiction treatment with Buprenorphine. The review indicates that the 
enrollee did not meet the criteria for coverage. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve myocardial perfusion imaging, tomographic (SPECT). You say that 
myocardial perfusion imaging, tomographic (SPECT) is medically necessary. The Plan denied your request. 
The Plan says myocardial perfusion imaging, tomographic (SPECT) does not meet the Medicare coverage 
criteria.  
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging, tomographic (SPECT) 
is covered when the criteria listed in the Medicare rules section of this decision 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 myocardial perfusion imaging, 
tomographic (SPECT). Our reviewer says that the requested myocardial perfusion imaging, tomographic 
(SPECT) is not considered medically necessary in this case. Our physician reviewer found that the enrollee has 
no cardiac symptoms. There is no documentation that the electrocardiogram (ECG) shows an uninterpretable 
pattern or that the enrollee is unable to exercise. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing 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 myocardial perfusion imaging, tomographic (SPECT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic 
(SPECT).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for cerebral perfusion analysis provided on February 19, 2023. 
 
You asked the Plan to pay for the cerebral perfusion analysis. You say that the cerebral perfusion analysis was 
medically necessary. The Plan denied your request. The Plan says that the requested cerebral perfusion analysis 
done while in the emergency room. does not meet the Medicare LCD coverage criteria. There is no 
documentation of acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the 
proximal anterior circulation. 
 
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 pay for the cerebral perfusion analysis. Our reviewer 
says that the cerebral perfusion analysis is considered medically necessary in this case. Our physician reviewer 
found review of the CTA done on February 19, 2023 revealed an abnormal appearance of the M2 segment of 
the left middle cerebral artery and possible dissection. The CT perfusion study thus was reasonable since 
intervention may have been indicated.  
 
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 cerebral perfusion analysis have been met. Therefore, we decided that the 
Plan has to pay for cerebral perfusion analysis provided on February 19, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service February 27, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service February 27, 2023.