Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve block, stellate ganglion. 
 
You asked the Plan to pre-approve nerve block, stellate ganglion. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 nerve block, stellate ganglion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is still considered experimental therapy.   UpToDate citation, 
randomized clinical trials have shown mixed results, and further trials investigating the use of stellate 
ganglion blockade as an adjunctive PTSD treatment are warranted. The request is deemed 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 nerve block, stellate ganglion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nerve block, stellate ganglion.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate. 
 
You asked the Plan to pre-approve Nplate. The Plan denied your request. The Plan says Nplate is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Nplate. Our reviewer says that Nplate is 
not medically necessary. Our physician reviewer found that the requested use of Nplate is not FDA- approved. 
Nplate is also not supported by one of the major drug compendia or by clinical research. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87502, 87532, 87798 
and U0005) provided on November 29, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says there are insufficient records to support that 
the services provided were the services requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, the physician order form includes only a note that an "upper respiratory infection - viral" panel is 
requested. However, there is no documentation provided to indicate which pathogens are included within this 
panel. Without this information, we cannot verify that the services provided are what was requested by the 
enrollee's treating physician, or that they were medically necessary. Therefore, we decided that the Plan does 
not have to pay for the laboratory services (87496, 87498, 87502, 87532, 87798 and U0005) provided on 
November 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires care to maintain 
safety and health. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial 
in nature. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve private duty nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that  the service is medically necessary.  
The Plan denied your request. The Plan says the bone marrow aspirate is not medically necessary. The Plan 
says medical studies have not shown that this procedure is helpful for treatment of the enrollee's health 
problem.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate is experimental when used as bone graft material in spine surgery. 
 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myriad MyRisk hereditary cancer/BRCA gene testing 
(81432, 81433). 
 
You asked the Plan to pre-approve hereditary cancer testing. You say that your child has been tested and has 
been shown to have the BRCA2 genetic defect, so you feel you should be tested as well. The Plan denied your request. The Plan says this test would be considered a screening as you have no personal history of breast, 
pancreatic or prostate cancer. This test is not medically necessary when provided as a screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary cancer testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve Myriad MyRisk hereditary cancer/BRCA gene testing (81432, 81433).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 26, 2022, billed with 
codes 87481, 87500, 87640, 87652, 87653, 87798, 87899 and 87900. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 26, 2022, billed with codes 87481, 87500, 87640, 87652, 87653, 87798, 87899 and 
87900.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve the percutaneous vertebroplasty. You say that the surgery is medically 
necessary.  The Plan denied your request. The Plan says  the percutaneous vertebroplasty 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 percutaneous vertebroplasty. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing edema and acute fracture 
that is less than 12 weeks old. 
 
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 percutaneous vertebroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the percutaneous vertebroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. The Plan denied your request. The Plan says 
pembrolizumab is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pembrolizumab. Our reviewer says that 
pembrolizumab is not medically necessary. Our physician reviewer found that the requested use of 
pembrolizumab is not FDA-approved. Also, pembrolizumab is not supported by one of the major drug 
compendia or by clinical research.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary bicycle. 
 
You asked the Plan to pre-approve a stationary bicycle. You say that you do not feel that significant weight-
bearing and walking is an appropriate option for you, hence the need for a stationary bicycle. The Plan denied 
your request. The Plan says the stationary bicycle requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stationary bicycle.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that with the enrollee's recent falls it puts them at a very 
high risk for future fractures and therefore anabolic therapy is indicated in this situation. The Plan denied your 
request. The Plan says that the 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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug Forteo. Also, there is no indication that the Plan's required drug would likely be less effective of 
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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a wheelchair lift on the outside of the 
enrollee's home. 
 
You asked the Plan to pre-approve repairs to a wheelchair lift on the outside of the enrollee's home. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says repairs to a 
wheelchair lift for use on the outside of the enrollee's home is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve repairs to a wheelchair lift on the outside of the enrollee's 
home.
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 the HBOT. You say that you need this. The Plan denied your request. The 
Plan says the records do not show that you have failed standard wound therapy. 
 
The Plan follows Medicare rules. Medicare rules say that the use of HBO therapy is covered as adjunctive 
therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard 
wound therapy and must be used in addition to standard wound care. 
 
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 HBOT. Our reviewer says that the 
request for hyperbaric oxygen therapy (HBOT) is not medically necessary. Our physician reviewer found the 
provided documentation shows that the enrollee's wound had significant reduction in size in only two weeks. 
The records do not show that the enrollee is suffering with a Wagner grade 3 or higher diabetic ulceration. 
Therefore, the reviewer found that the request for HBOT 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 HBOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 84403 billed for date of service April 19, 2023. 
 
You asked the Plan to pay for code 84403. You say that this service was necessary and is supported as billed. 
The Plan denied your request. The Plan says procedure code 84403 billed for date of service April 19, 2023. 
 
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 code 84403 is Testosterone; total. 
 
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 code 84403. Our reviewer says that code 84403 is not 
supported by the medical record. Our reviewer found the procedure report documents "TESTOSTERONE 
363.96".  In this case there is insufficient documentation to confirm a total testosterone has been performed.  A 
total testosterone test measures free testosterone and testosterone that's attached to proteins. This is the most common type of test. A free testosterone test measures only the "active" form of testosterone. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 84403 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 84403 billed for date of service April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hepatology services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that the enrollee is waiting for the appointment. The 
Plan denied your request. The Plan says services are available within the network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
hepatology services to be provided by an out-of-network (OON) provider.
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 Briumvi. You say that Briumvi is the best disease treatment for the enrollee.  
The Plan denied your request. The Plan says that the 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 Briumvi. Our reviewer says that 
Briumvi is not medically necessary. Our physician reviewer found that the enrollee has multiple sclerosis, and 
the medication is a new start. However, there is no indication that the enrollee has tried and failed the Plan's 
preferred step one alternative. Also, there is no indication that the enrollee has a contraindication to or would 
have an adverse effect from the Plan's preferred step one alternative. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Briumvi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Briumvi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the periapical x-rays (D0220, D0230) 
provided on April 28, 2022, the periodontal scaling and root planning (D4341) provided on August 25, 2022, 
and the periodontal maintenance (D4910) provided on February 15, 2023. 
 You asked the Plan to waive the coinsurance for the dental services. You say that the wrong codes were used 
when billing these claims. 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). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for class 2 basic services.  
 
You have been asked to pay 50% coinsurance of the allowed amount for the dental services provided on April 
28, 2022, August 25, 2022, and February 15, 2023. These services falls within the dental services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the periapical x-rays (D0220, D0230) 
provided on April 28, 2022, the periodontal scaling and root planning (D4341) provided on August 25, 2022, 
and the periodontal maintenance (D4910) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation services billed with code 99222 for date of service April 5, 
2023. 
 
You asked the Plan to pay for the observation services. You say that the medical records support the services 
billed. The Plan denied your request. The Plan says that you billed this observation code with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must use the POS code that reflects the 
location where the face-to-face service with the patient occurs. 
 
In this case, the patient received observation level services in the emergency room. That is why POS code 23 
was billed.  The Plan argues that POS 23 is not to be used for observation services.  However, CMS contractors 
have already spoken to this and determined that is not true. In fact, one of the CMS Part B contractors 
(National Government Services) has issued a bulletin clarifying CMS' policy regarding this specific issue.  That 
bulletin states "Observation services are billable in POS 19 (Off Campus-Outpatient Hospital), POS 22 (On 
Campus-Outpatient Hospital) and POS 23 (Emergency Room  Hospital). The correct POS for the claim is 
determined by the patients location in the facility at the time of the service." This clearly shows that CMS 
allows POS 23 to be used for observation care that is rendered in the emergency room setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the observation services have been met. Therefore, we decided that the Plan has to pay for 
observation services billed with code 99222 for date of service April 5, 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.