Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (CPT Code K0606) on April 19, 2020. 
 
You asked the Plan to pay for the service. You say that the service is necessary. The Plan denied your request. 
The Plan says the service is not 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Medicare criteria are not met and medical necessity cannot be determined. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT 
Code K0606) on April 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee walker provided on April 11, 2020 to May 9, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for a knee walker. You say that you paid for this out-of-pocket and you would like 
the Plan to reimburse you. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that there is no network deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a knee walker provided on April 11, 2020 to May 
9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided from April 17, 
2020 to May 17, 2020. 
 
You asked the Plan to pay for a total electric hospital bed. You say that you were told this would be covered. 
The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric beds will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue is not considered reasonable and necessary. Based 
on this information, we decided that Medicare rules for coverage of a total electric hospital bed have not been 
met. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided 
from April 17, 2020 to May 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 8, 2020 to 
February 18, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says enrollee's 
must receive care from an in-network provider. In most cases care received from an out-of-network provider 
will not be 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided from January 8, 2020 to February 
18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on December 
17, 2019. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; therefore, the billed service cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the 
presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99152) provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the blood pressure cuff. We decided that the Plan does not have to 
pre-approve the ambulatory blood pressure monitoring device.  
 
You asked the Plan to pre-approve the blood pressure measuring device. You say that you would like 
reconsideration because the member has multiple comorbidities and is high risk for having worse outcome. The 
Plan says that the member does not meet the Medicare rules for approval. 
 
We decided that the Plan has to pre-approve the blood pressure cuff.  
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 blood pressure cuff. Our reviewer 
says that a home blood pressure cuff is considered reasonable and medically necessary for this member given 
previous poor control and the pandemic making in-person visits risky.  
 
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 blood pressure cuff have been met. Therefore, we decided that the Plan has 
to pre-approve the blood pressure cuff.  
 
We also decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring device. 
 
The Plan follows Medicare rules. Medicare rules say that the evidence is sufficient to determine that ABPM is 
reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries under specific 
circumstances. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ambulatory blood pressure monitoring 
device. Our physician reviewer found ambulatory blood pressure monitoring is not medically necessary for this 
member, because she is not suspected of having white-coat hypertension or masked hypertension. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulatory blood pressure monitoring device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ambulatory blood pressure monitoring device. 
 
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 waive the copayment for the office visit (99214) provided on May 6, 
2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $40 
copayment per visit to a specialist.  
 
You have been asked to pay a $40 copayment for the telehealth specialist office visit provided. The record 
shows that the telemedicine reminder brochure issued to enrollees with an effective date of March 9, 2020, 
indicates that telemedicine service availability has expanded to specialists. Regular specialist cost sharing will 
apply to all expanded telemedicine services not related to COVID-19 testing. 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 the office visit (99214) provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 19, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous passive motion device (E0935) January 18, 
2019 to February 5, 2019. 
 
You asked the Plan to pay for the continuous passive motion device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the continuous passive motion device is not covered for 
this application. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pay for a continuous passive motion device (E0935) January 18, 2019 to February 5, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Gelsyn-3. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects 
for the enrollee. Without the support of the documentation, Gelsyn-3 is not approved as step criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home services provided on December 20, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for rest home services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for rest home services provided on December 20, 
2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no skilled or skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex 
wound care or other ongoing SNF level skilled nursing need. Your functional level does not require skilled 
therapy services. The services are not required on a daily basis, or on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 20, 2020 to 
April 18, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 20, 2020 to April 18, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has 
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 Prolia. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of an oral 
bisphosphonate drug and zoledronic acid 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
services coded 87798 provided on April 28, 2020. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid (DNA or RNA) services. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not payable. 
 
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 find that CPT code 87798 is not supported in the medical record. Specifically, the standard of care for 
urinary tract infection testing is urinalysis with urine culture and sensitivity. A urine culture and sensitivity was 
not performed by the documentation. Based on this information, we decided that Medicare rules for coverage 
of the infectious agent detection by nucleic acid (DNA or RNA) services have not been met. Therefore, we 
decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
services coded 87798 provided on April 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve oral surgery to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria has not been met. 
 
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 
oral surgery to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there was no 
indication that the enrollee had back pain or leg pain at the noted visits. Although strength on September 3, 
2020 was noted to be 4+/5 in the left lower extremity with normal sensation and normal reflexes, strength 
testing was noted to be 5/5 throughout on September 10, 2020, with normal sensation and no cerebellar 
findings. Gait was noted to be "somewhat ataxic". The requested study is not medically or reasonable based on 
the documentation provided. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).