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

 
We decided that the Plan does not have to pay for the genetic testing provided on November 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says testing for these 
genes is not a Medicare benefit. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that the gene panel includes the FANCC gene. Testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service. Based on this information, we decided that Medicare rules for coverage of 
the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) of 22 or more classes 
provided on January 7, 2022. 
 
You asked the Plan to pay for the definitive UDT. You say that it was not known that authorization was 
required. The medically necessary testing should be paid. The Plan denied your request. The Plan says payment 
was made for the presumptive drug testing. However, there is no information from the medical record to ensure 
the definitive testing meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive UDT orders should be individualized 
based on clinical history and risk assessment and must be documented in the medical record. 
 
We looked at the file and Medicare rules. There was no progress note from the ordering provider to confirm the 
testing requested was based on clinical history or risk assessment. Based on this information, we decided that Medicare rules for coverage of the definitive UDT have not been met. Therefore, we decided that the Plan does 
not have to pay for the definitive urine drug testing (UDT) of 22 or more classes provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2335 and D2332) provided by a 
participating provider on January 24, 2022. 
 
You asked the Plan to pay for resin-based composites. You say that you chipped your tooth. The Plan denied 
your request. The Plan says the rendered dental services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 resin-
based composites (D2335 and D2332) provided by a participating provider on January 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee has made significant progress 
with weight-bearing activities and has improved tolerance for weight-bearing activities, allowing for inclusion 
of more functional activities. The Plan denied your request. The Plan says the 5 additional PT visits are not 
reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. Our reviewer 
found that the patient has had prior therapy and the documentation does not reveal that the patient requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our 
physician reviewer also found that the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 5 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee is in excruciating pain and is in need of 
Orthovisc to relieve the pain. The Plan denied your request. The Plan says the documentation requirements for 
coverage of Orthovisc have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that repeat injection of a hyaluronate such as Orthovisc 
is only allowed when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Orthovisc. Our physician reviewer found the documentation 
does not support that there was a reduction in the enrollee's symptoms with previous injections of Orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 23, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on November 23, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the coinsurance for the supply allowance for 
a therapeutic continuous glucose monitor (K0553) provided on January 27, 2022. 
 
You asked the Plan to issue reimbursement of the coinsurance. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly to the items 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 $0 
copayment for diabetic monitoring supplies rendered by a preferred diabetic supplier and a 20% coinsurance 
for diabetic monitoring supplies rendered by a diabetic supplier.  Additionally, you must pay a 10% coinsurance for diabetic monitoring supplies rendered by a network retail 
pharmacy. 
 
You have been asked to pay $98.27 (Plan allowed amount of $491.34 x 20% coinsurance) for the diabetic 
monitoring supplies provided by a diabetic supplier. The supplies in this case were not rendered by a preferred 
diabetic supplier. 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 issue reimbursement of the coinsurance for the supply 
allowance for a therapeutic continuous glucose monitor (K0553) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services, chemotherapy administration, a hospital 
outpatient clinic visit, a dexamethasone injection, a pemetrexed injection, a therapeutic, prophylactic, or 
diagnostic injection provided on August 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services, chemotherapy administration, a hospital outpatient clinic 
visit, a dexamethasone injection, a pemetrexed injection, a therapeutic, prophylactic, or diagnostic injection. 
You say that although you did not obtain authorization for this service with this Plan, you did obtain it through 
a different Plan because that is who you thought the patient had coverage for this date of service. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are 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 laboratory services, chemotherapy administration, 
a hospital outpatient clinic visit, a dexamethasone injection, a pemetrexed injection, a therapeutic, prophylactic, 
or diagnostic injection provided on August 19, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
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 enrollee has a high enough fracture risk and history 
of fracture, and therefore medically meets criteria as if she has osteoporosis and needs Denosumab. The Plan 
denied your request. The Plan says Prolia is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and 
Drug Administration (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 Prolia. Our reviewer says that the 
enrollee does not meet the criteria for coverage for the use of Prolia. Our physician reviewer found Prolia 
(J0897) is FDA-approved for the treatment of post-menopausal osteoporosis. The provided records in this case 
do establish a diagnosis of osteoporosis. Our reviewer found that the documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Our physician 
reviewer also found that the provided records document the enrollee has a history of vitamin D deficiency and 
no laboratory reports were provided documenting that the enrollee has adequate vitamin D and calcium levels 
as required for safe use of Prolia. 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and biopsy (45380). 
 
You asked the Plan to pre-approve a colonoscopy and biopsy. You say that it is your professional opinion that a 
screening colonoscopy be done at this time (5 years since the last colonoscopy). The Plan denied your request. 
The Plan says the screening colonoscopy that you are requesting does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a diagnostic colonoscopy can be covered if the 
enrollee has a covered indication, and has no contraindications, listed in the Medicare rules section 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 a colonoscopy and biopsy. Our 
reviewer says that the elements of the coverage criteria are not satisfied, and the requested service is not 
recommended. Our physician reviewer found the record indicates that the enrollee underwent a colonoscopy in 
2016, which after irrigation was deemed to be a good prep and a normal study. Our reviewer also found that the 
record provided does not establish the presence of an enumerated condition for which coverage of the 
requested service is available. 
 
 
 
 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 colonoscopy and biopsy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a colonoscopy and biopsy (45380).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that these services were authorized. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not 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 lab testing provided on January 21, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be more stable and improving and should only require short-term acute 
care hospital services that can be safely completed at the current facility until more appropriate for a lower 
level of care. There are no services at the LTACH that you require that are not already available and covered at 
the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasounds, breast, unilateral, complete (76641-LT, 
76641-RT) provided on January 22, 2022. 
 
You asked the Plan to pay for the ultrasounds. You say that these services were billed correctly. The Plan 
denied your request. The Plan says the documentation provided does 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 code 76441 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
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 the ultrasounds. Our reviewer says that these services are not 
supported as billed. Our reviewer found the procedure report does not describe a complete ultrasound 
consisting of examination of all four quadrants of the breast and retroareolar region for either the left or right 
side. The documentation does not include enough information to confirm that complete ultrasounds have been 
performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasounds have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasounds, breast, unilateral, complete (76641-LT, 76641-RT) provided on January 22, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve three-dimensional (3D) conformal image-guided radiation therapy 
(IGRT). 
 
You asked the Plan to pre-approve 3D conformal IGRT. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, 
because this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 3D conformal IRGRT. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the rationale provided for the need for 3D radiotherapy is that the lesion is too thick 
for electron therapy. The rationale provided for the need for IGRT is that the treatment abuts an adjacent 
treatment field. These are plausible rationales for 3D radiation and for IGRT, even with low-dose delivery. 
Clearly this is not a typical skin cancer that can readily be treated with a small electron therapy field, but rather 
with a complex shape. It is within accepted standards of medical practice to perform 3D/IGRT for complex 
treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D conformal IRGRT have been met. Therefore, we decided that the Plan has 
to pre-approve three-dimensional (3D) conformal image-guided radiation therapy (IGRT).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 700 units of Botox every 90 days. 
 
You asked the Plan to pre-approve the requested dose. The Plan denied your request. The Plan says the request 
exceeds the dose indicated by accepted standards. 
 
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 the requested dose. Our physician 
reviewer found that the enrollee has a medical history of multiple sclerosis with diagnoses of cramp and spasm 
and right foot drop. Botox is approved for spasticity, but the dose of 700 units every 90 days exceeds the 
recommended dosage. The requested dose is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. The requested use does not meet Medicare criteria 
for safe and effective and otherwise reasonable and necessary for this enrollee. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested dose have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 700 units of Botox every 90 days.