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

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 88305) provided on 
September 16, 2021, by an out-of-network providers. 
 
You asked the Plan to pay for the out-of-network service. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by the 
enrollee's network primary care provider (PCP), and the services were not urgent or emergent, nor were they 
approved in advance. 
 
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 had network providers 
available who could have provided 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 the laboratory service (CPT code 88305) provided 
on September 16, 2021, by an out-of-network providers.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on 
August 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 81479 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained at a campus outpatient hospital, POS 22. Also, the laboratory results submitted 
indicate the specimen was collected on August 24, 2021, and received by the lab on August 25, 2021. Of note, 
the patient resides in Wisconsin and the billing laboratory is in Illinois; therefore, the billed code cannot be 
verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, 
we decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on 
August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total knee arthroplasty (CPT code 27447-AS) provided 
on May 10, 2021. 
 
You asked the Plan to pay for the total knee arthroplasty. You say that the correct modifiers were billed on the 
claim. The Plan denied your request. The Plan says the appeal states modifiers AS and RT were billed, 
however, after reviewing the paper claim, it reflects the only modifier billed was AS. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 The procedure code is inconsistent with the modifier used. This should be billed with the appropriate code for 
these services. This code was not billed with the appropriate anatomical modifier. Based on this information, 
we decided that Medicare rules for coverage of the total knee arthroplasty have not been met. Therefore, we 
decided that the Plan does not have to pay for the total knee arthroplasty (CPT code 27447-AS) provided on 
May 10, 2021.
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 the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 health plans denial of LTACH coverage should be upheld. The enrollee is 
currently undergoing treatment at an ACH. The enrollee is not intubated/ventilated. There is no evidence that 
the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide 
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can 
remain at the current ACH until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing LTC needs. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lancet trueplus 33G twist lancets and prodigy control 
solution and testing strips, provided on April 23, 2020. 
 
You asked the Plan to pay for the lancet trueplus 33G twist lancets and prodigy control solution and testing 
strips. You say that the items are medically necessary. The Plan denied your request. The Plan says the 
requested items are not the preferred brand. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers 
 
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 lancet trueplus 33G twist lancets and 
prodigy control solution and testing strips. Our reviewer says that the member does not need these items. Our 
physician reviewer found there is no reason given why the nonpreferred strips -truemetrix/trueplus- are 
required    as opposed to the preferred brand. 
 
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 lancet trueplus 33G twist lancets and prodigy contorl solution and testing 
strips have not been met. Therefore, we decided that the Plan does not have to pay for the lancet trueplus 33G 
twist lancets and prodigy control solution and testing strips, provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration (90471) Zoster (shingles) 
vaccine (90750) provided October 20, 2021. 
 
You asked the Plan to pay for the injection services. You say that before you went for your shingle shot you 
called and asked if you were covered. You cannot afford to pay for this. The Plan denied your request. The 
Plan says this vaccine is not payable under the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for immunization administration (90471) Zoster (shingles) vaccine (90750) 
provided October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine molecular polymerase chain reaction (PCR) panel 
testing provided on August 31, 2021. 
 
You asked the Plan to pay for PCR testing. You say that this testing was ordered by the treating physician who 
made the determination of medical necessity. The Plan denied your request. The Plan says the denial of 
payment for this testing is correct, because there is a lack of support for the clinical utility of this testing. 
 
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 PCR testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found urine PCR amplification techniques raise considerable concerns regarding 
contamination from one specimen to another, creating the potential for false positive results. The interpretation 
of CPR results may also be challenging. PCR may amplify fragments of nucleic acids representing dead 
microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and 
positive/negative predictive values of PCR have not been reported in large groups of patients for many of the 
microorganisms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PCR testing have not been met. Therefore, we decided that the Plan does not 
have to pay for urine molecular polymerase chain reaction (PCR) panel testing provided on August 31, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for treatment with Talimogene laherparepvec (J9325) provided on January 
10, 2019. 
 
You asked the Plan to pay for Talimogene laherparepvec. You say that the drug at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met because the prescribed use of the drug is experimental/investigational. 
 
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 pay for Talimogene laherparepvec. Our reviewer 
says that the drug at issue is medically reasonable and necessary in this case. Our physician reviewer found that 
Talimogene laherparepvec was approved by the FDA to treat unresectable, injectable cutaneous, subcutaneous, 
and nodal melanoma with limited visceral disease. This approval was based on data from a Phase III trial of 
436 patients with unresectable, injectable stage III or IV melanoma with a limited visceral disease burden. Per 
the medical notes in the case record, in this case Talimogene laherparepvec is being used for the treatment of 
intransit metastases. The documentation supports that the drug at issue is safe and effective and otherwise 
reasonable and necessary 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 Talimogene laherparepvec have been met. Therefore, we decided that the Plan 
has to pay for treatment with Talimogene laherparepvec (J9325) provided on January 10, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary 
for your condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 4, 2021. 
 
You asked the Plan to pay for the visit. You say that kindly review the attached medical records and you 
request for processing of the denied codes towards payment. The Plan denied your request. The Plan says there 
is evidence of misrepresented services. 
 
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 outpatient office visit (99202) 
provided March 4, 2021 have been met. The records submitted do not support that there was actual contact between the doctor and the enrollee. There is no evidence of an established relationship between the enrollee 
and the physician. The Plan had also requested additional records from the provider without success. Therefore, 
we decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 4, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an abatacept (Orencia) injection (CPT J0129) and 
administration (CPT 96413) under claim number 2104130F2071 provided on April 12, 2021. 
 
You asked the Plan to waive the coinsurance for the injection and administration. You say that you would have 
opted out of the injections if you knew the cost ahead of time. The Plan denied your request. The Plan says that 
the correct coinsurance was applied. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). Specifically, the Plan has not forwarded the 2021 EOC or an 
Explanation of Benefits (EOB) to substantiate the charges. Without this contract information, we are unable to 
verify the cost share amounts applied to any services rendered for this appeal. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the Plan's denial is not substantiated, so we must 
find in your favor. Therefore, we decided that the Plan has to waive the coinsurance for an abatacept (Orencia) 
injection (CPT J0129) and administration (CPT 96413) under claim number 2104130F2071 provided on April 
12, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on March 12, 2022 with weakness and failure to thrive. The therapy notes dated March 17, 2022 state that he is 
able to ambulate three feet with a rolling walker and minimal assistance. He received three attempts to stand. 
He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily 
basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 
You asked the Plan to pre-approve Hymovis. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria 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 Hymovis. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 
67-year-old male with bilateral primary osteoarthritis of the knee. In this case, the provider has recommended 
viscosupplementation therapy with Hymovis. The enrollee has not trialed the Plans preferred 
viscosupplemental treatments such as Euflexxa, Synvisc, or Synvis-One. Step therapy, as outlined by the plan, 
requires that at least one these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered or that the Plans required drugs would likely be less effective and/or 
likely have adverse effects for the enrollee. Without the support of the documentation, Hymovis 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 Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 16, 2021. 
 
You asked the Plan to pay for the office visit. You say that kindly review the attached medical records and 
request for processing of the denied codes towards payment. The Plan denied your request. The Plan says there 
is evidence of misrepresented service. 
 
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 outpatient office visit (99202) 
provided March 16, 2021. have been met. there is no evidence of an established relationship between the 
enrollee and the physician. The Plan had also made multiple attempts to obtain additional records from the 
provider without success. Therefore, we decided that the Plan does not have to pay for the outpatient office 
visit (99202) provided March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on September 
30, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 70450 may be eligible for payment when billed with 
CPT code 70496. The claim information does not show that the code at issue was billed with a modifier 
suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan 
have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography 
(CT) scan provided on September 30, 2021.