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

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 2, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 81057: Carbamepazine; free 
 
CPT 80159: Clozapine 
 
CPT 80162: Digoxin; total 
 
CPT 80173: Haloperidol 
 
CPT 80177: Levetiracetam 
 
CPT 80201: Topiramate 
 
 
 
 
HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed 
 
CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or 
procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without 
chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes 
sample validation when performed, per date of service 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation submitted did not include a completed physician order/lab requisition or medical records stating 
exactly what tests are to be performed. Blood specimen collection is by venipuncture; however, the lab 
requisition states a urine specimen was collected. Also, the laboratory test results for the billed code were not 
submitted; therefore, the billed services cannot be verified. 
 
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 pay for drug testing services provided to the enrollee on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 30, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there are no concerning symptoms or history of drug abuse/misuse. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee meets the criteria for the definitive urine drug testing (UDT) provided to the enrollee on October 30, 
2019. A basic screening test appears to have been appropriate 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Axogen Graft nerve wrap. 
 
You asked the Plan to pre-approve an Axogen Graft nerve wrap. You say that the requested Axogen Graft 
nerve wrap is medically necessary. The Plan denied your request. The Plan says the requested Axogen Graft 
nerve wrap 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 an Axogen Graft nerve wrap. Our 
reviewer says that the requested Axogen Graft nerve wrap is not medically necessary. Our physician reviewer 
found this enrollee presents with paresthesias in both the median and ulnar nerve distributions with constant 
ring and little finger symptoms. She is status post right ulnar nerve transposition 5 years ago. Clinical exam 
findings are consistent with right ulnar neuropathy at the elbow and right carpal tunnel syndrome. There is 
electrodiagnostic evidence of right median neuropathy and reported minimally prolonged ulnar sensory 
latencies. She is scheduled for right carpal tunnel release and right revision ulnar nerve transposition with 
possible nerve wrap. The provider has requested the use of an Axogen nerve wrap to protect or insulate the 
nerve from the risk of recurrent adhesions. A search of PubMed indicated that there is a lack of large volume, 
long-term peer-reviewed outcome studies to support the use of nerve wrap for this enrollee as discussed above. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request. Therefore, this request for Axogen nerve wrap would not be considered 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 an Axogen Graft nerve wrap have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Axogen Graft nerve wrap.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was treated for a broken leg and a stroke. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The record does support a need for physical and 
occupational therapy but there is no need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided by 
on May 18, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that your dentist 
recommended the procedure or your tooth could be lost. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure (D1999) provided by on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the enrollee is with a history of hypertension, smoking, diabetes, Crohn's disease, ischemic 
cardiomyopathy and NYSHA Class III congestive heart failure with reduced LV ejection fraction (20-25%) 
requiring hospitalization. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, 
concerns have been raised about potential bias in this trial calling into question the results. Therefore, the 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular ablation. 
 
You asked the Plan to pre-approve endovascular ablation. You say that the requested endovascular ablation is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested endovascular ablation. 
 
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 endovascular ablation. Our reviewer 
says that the enrollee does not meet criteria for the requested endovascular ablation. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical 
necessity/appropriateness of the procedure in question.  The documentation does not describe significant or 
unmanageable symptoms.  Coverage requires that symptoms be attributable to the veins in question.  It is not 
possible to attribute leg symptoms in an elderly patient with numerous cardiovascular risk factors without an 
assessment of lower extremity arterial perfusion.  It is not possible to determine the appropriateness of greater 
saphenous vein ablation without an assessment of lower extremity arterial perfusion. There does not appear to 
have been an effort at treating conservatively prior to planning greater saphenous vein ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovascular ablation.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a swollen and painful foot 
which required amputation. Medical problems are stable. She is currently in a skilled nursing facility where 
medical needs are being met. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The record does support a need for physical and 
occupational therapy but there is no need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network Gynecologic Oncology 
providers available to the enrollee that can provide the same care and treatment being requested. 
 
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. 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 12, 2020 to April 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 a $100 
copayment per day for days 1-5. There is a $0 copayment per day for days 6-90 for inpatient hospital care.  
 
You have been asked to pay a $100 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $300 ($100 x 3 days = $300). An inpatient hospital stay falls within the 
inpatient hospital care 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 copayment for an inpatient 
hospital stay provided by a participating provider on April 12, 2020 to April 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty. 
 
You asked the Plan to pre-approve vertebroplasty. You say that the requested vertebroplasty is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
vertebroplasty. 
 
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 vertebroplasty. Our reviewer says that 
the enrollee does not meet criteria for the requested vertebroplasty. Our physician reviewer found this enrollee 
presents with a traumatic superior endplate fracture at L2 on 6/9/20 due to a fall off a ladder. He reports 
persistent severe pain that was incapacitating. He has failed to improve with conservative treatment including 
activity modification, medications, and an epidural steroid injection. He is unable to use a brace due to large 
body habitus. Under consideration is a request for L2 vertebroplasty. Medicare criteria have not been met as 
outlined above. There is no evidence of an acute osteoporotic vertebral compression fracture. There is no 
evidence of progression of progression of vertebral body height loss, > 25% vertebral body height reduction, or 
kyphotic deformity. This injured worker has a traumatic fracture at L2 that was over 10 weeks old at the time 
of this request. Therefore, the enrollee does not have a covered indication for the requested vertebroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional LogistiCare mileage. 
 
You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 36 one-way trips 
per calendar. The Plan says that each one-way trip must not exceed 50 miles. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way transportation trips per year, not to exceed 50 miles per one-
way trip.  
 
We looked at your request, the records in the case file, and the rules. The Plan's transportation benefit only 
covers up to 36 one-way trips per year not to exceed 50 miles per one-way trip. The file shows you are asking 
for a total of 131 miles per one-way trip, which is over the allotted 50 miles per one-way trip. Therefore, we 
decided that the Plan does not have to pre-approve additional LogistiCare mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital inpatient services provided April 
12, 2020 to April 15, 2020. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you were never advised that 
you would have a copayment. The hospital kept you there and you wanted to leave and cannot afford to pay for 
this. The Plan denied your request. The Plan says this claim was processed and the correct copayment was 
applied per the plan benefits 
 
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 $100 
copay per day for days 1-5 for Inpatient hospital care.  
 
You have been asked to pay $300 for inpatient services. The inpatient services fall within the Inpatient hospital 
care 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 copayment for hospital inpatient services 
provided April 12, 2020 to April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
23, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) G0482 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code G0483 is not supported in the medical record. Specifically, the case file does not 
contain a valid physician order that would support these services. 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 drug testing services provided to the enrollee on December 23, 2019.