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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 18, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided documentation did not clearly explain why the standard of care testing 
methods (urinalysis and culture) were not utilized here. Current evidence does not sufficiently support PCR 
testing over these testing methods. Therefore, this request for PCR urine panel testing will be considered not 
medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 tests provided on June 30, 2023. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you want to be reimbursed payment. 
 The Plan denied your request. The Plan says the items are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 tests are considered an OTC item. Therefore, we decided that the Plan does not have to pay for the 
COVID-19 tests provided on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat minimally invasive lumbar decompression 
(MILD) procedure at L3-4 and initial MILD procedure at L4-5. 
 
You asked the Plan to pre-approve the MILD procedures. You say that the enrollee is in need of a the MILD 
procedure to be performed at L3-4 and L4-5. You say that the enrollee experiences symptoms of lumber 
stenosis. You also say that this is medically necessary. The Plan denied your request. The Plan says this cannot 
be covered because you have had this procedure within the last 12 months. 
 
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 MILD procedures. Our reviewer 
says that the requested repeat minimally invasive lumbar decompression (MILD) procedure at L3-4 and the 
initial MILD procedure at L4-5 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 request to be an effective and/or safe treatment for the noted pathology. Overall, the peer-reviewed 
literature finds only modest evidence for efficacy. Further studies are needed to prove the efficacy of this 
treatment over the gold standard surgical procedures. Additionally, detailed documentation regarding a trial and 
failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. There are 
no updated imaging studies provided post procedure to support pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the reviewer found that the requested repeat MILD (minimally invasive lumbar decompression) 
procedure at L3-4 and an initial MILD procedure at L4-5 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 MILD procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat minimally invasive lumbar decompression (MILD) procedure at L3-4 
and initial MILD procedure at L4-5.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab injections. 
 You asked the Plan to pre-approve denosumab injections. You say that you have osteoporosis and have been 
off the medication due to dental surgery. The Plan denied your request. The Plan says the enrollee does not 
meet the Part B step-therapy requirements for the requested injection. 
 
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 denosumab injections. Our reviewer 
says that the requested drug does not meet the criteria necessary for approval. Our physician reviewer found 
that the plan requires a trial of an injectable bisphosphonate (e.g., Pamidronate, Zoledronic Acid) before they 
will approve the requested drug. Based on the medical records and Medicare-approved major drug compendia, 
there is no indication that you have tried and failed the required drugs or that the plan's required drugs would 
likely be less effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of denosumab injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve denosumab injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need attention for rehabilitation services ever 
since you had weight loss surgery to learn how to walk again with physical therapy. The Plan denied your 
request. The Plan says your records do not indicate that you need to be seen by a rehabilitation doctor three 
times weekly for evaluation of functional and medical goals and progress or that you need an intensive care 
team. The Plan says services may be provided at 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical records 
supports a need for physical 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. It is not a 
reasonable expectation that you 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic rhizotomy. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary to address pain and 
restore function. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that an endoscopic rhizotomy is considered experimental/investigational. There is no evidence 
that this is a superior technique compared to the standard approach to rhizotomy. 
 
 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 an endoscopic rhizotomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary tract infection (UTI) lab panel provided on December 
26, 2022. 
 
You asked the Plan to pay for the UTI panel. The Plan denied your request. The Plan says this testing 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 pay for the UTI panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a 
urine culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large 
multiplex PCR urinary tract infection panel tests. 
 
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 UTI panel have not been met. Therefore, we decided that the Plan does not 
have to pay for urinary tract infection (UTI) lab panel provided on December 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee's condition has stabilized, and 
he will require a multi-disciplinary approach for an extended period of time. The Plan denied your request. The 
Plan says the enrollee is receiving the necessary care in the acute care hospital and is unstable for transfer to an 
LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these services have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving, but that would be available at an LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the repeat RFA. You say that given the enrollee's medical history and 
treatment options, this is the best clinical option for the enrollee. The Plan denied your request. The Plan says 
these services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint radiofrequency ablation 
(RFA) at the same anatomic site is considered medically reasonable and necessary provided the patient had a 
minimum of consistent 50% improvement in pain for at least six (6) months. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided records do not support 
that the enrollee had 50% pain relief for at least six months. Therefore, the reviewer found that the requested 
RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve repeat radiofrequency ablation (RFA) (64635, 64636).
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 LTACH will provide a good outcome 
for the enrollee and a preventative measure to avoid acute care readmission. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 the enrollee has been stabilized and treated for their acute condition (necrotizing 
fasciitis). The enrollee is not on antibiotics or other intensive medical treatment. The enrollee is on routine 
hemodialysis for chronic kidney disease. The enrollee's wound management consists of twice daily wet to dry 
dressings, which is not complex. In addition, it does not appear that the enrollee will require inpatient hospital 
services meeting or exceeding 25 additional days. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care (99232) provided on January 31, 2023, 
to February 01, 2023. 
 
You asked the Plan to pay for the observation care (99232). You say that the services should be covered. 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 observation care 
(99232) provided on January 31, 2023, to February 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot (L4361) provided on November 7, 2022. 
 
You asked the Plan to pay for the walking boot. The Plan denied your request. The Plan says the required 
modifier was not billed.  
The Plan must follow Medicare rules. Medicare rules say that claim lines billed with codes without a KX, GA 
or GZ modifier will be rejected as missing information.  
 
We looked at the file and Medicare rules. In this case, code L4361 was not billed with modifier KX, GA, or 
GZ, as required by LCA A52457. Based on this information, we decided that Medicare rules for coverage of 
the walking boot have not been met. Therefore, we decided that the Plan does not have to pay for the walking 
boot (L4361) provided on November 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Briumvi. 
 
You asked the Plan to pre-approve the medication. You say that due to the enrollee's history they need a highly 
effective medication for their relapsing remitting multiple sclerosis. The Plan denied your request. The Plan 
says that step therapy requirements 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 the medication. Our reviewer says that 
the criteria for coverage of Briumvi have not been met. Our physician reviewer found that the Plan requires a 
trial of Ocrevus before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug. There is no documentation provided indicating that the Plan's required drug would likely be 
less effective 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Briumvi.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided on May 8, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT 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 was medically necessary. Our physician reviewer found that the 
enrollee is in treatment for a substance use disorder, not chronic pain. The testing was medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the definitive UDT for 22 or more drug classes have been met. Therefore, we 
decided that the Plan has to pay for the definitive urine drug testing (UDT) for 22 or more drug classes (G0483) 
provided on May 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device (E0486) purchased on May 1, 2023. 
 
You asked the Plan to pay for the oral device. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances generally are classified as dental 
devices and are not classified as durable medical equipment. The following items (not all-inclusive) are 
considered to be dental devices and will be denied as non-covered, not DME: 
 Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders 
Tongue retaining devices used to treat OSA and/or snoring 
All oral appliances used only to treat snoring without a diagnosis of OSA  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oral device have not been met. Therefore, we decided that the Plan does not have to pay for the 
oral device (E0486) purchased on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 7, 2023. 
 
You asked the Plan to pay for the medical services. You say that you billed with valid diagnosis codes. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that F33.3 has an Excludes1 note in relation to F22. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 7, 2023.