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

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that Retacrit is not available due to a national shortage. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Procrit or 
Retacrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that the enrollee has tried and failed the preferred drugs, Procrit or Retacrit. The reviewer found that 
the documentation does not support that Procrit or Retacrit would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide testing strips. 
 
You asked the Plan to pre-approve Accu-Chek Guide testing strips. The Plan denied your request. The Plan 
says the requested supplies are not a preferred brand and are not covered under your contract. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands as preferred and may 
limit coverage to only those preferred brands as long as the enrollee retains access to all medically necessary 
items. Medicare rules also say that information must be submitted in order to confirm that Medicare coverage 
criteria have been met.   
We looked at the file and Medicare rules. The Plan contract clearly states that coverage of diabetic testing 
supplies obtained through the pharmacy is limited to Ascensia and LifeScan branded products. The test strips 
being requested are not made by these brands. There were no medical records provided, despite the Plan's 
reasonable requests for this documentation. There is no evidence that the preferred brand testing strips would 
not meet the enrollee's medical needs. There is no evidence that the requested off-brand testing strips are 
medically necessary over these preferred brand testing strips. There is no evidence that the enrollee has tried 
and failed the preferred brand. There is no evidence that the enrollee cannot use the preferred brand products 
for medical reasons. Based on this information, we decided that Medicare rules for coverage of Accu-Chek 
Guide testing strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-
Chek Guide testing strips.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for WATS 3D biopsy testing provided on February 12, 2021. 
 
You asked the Plan to pay for lab test. You say that the enrollee's treating physician ordered this testing after 
making a professional determination of medical necessity. The Plan denied your request. The Plan says that the 
denial of payment for this testing is correct, because medical literature and clinical practice guidelines do not 
support the use of this testing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice that this testing would not 
be covered. Without this information, we cannot determine whether the lab order made constituted plan-
directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or 
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for WATS 3D biopsy 
testing provided on February 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing provided on September 23, 
2021. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage of CxBladder testing was 
reaffirmed by Medicare as of revisions made to the guidelines on October 4, 2018.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder Detect testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CxBladder Detect testing provided on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 5, 2020, to 
October 8, 2020, as billed with DRG 417. 
 
You asked the Plan to pay for inpatient services billed with DRG 417. You say that these services were 
medically necessary and are supported as billed.  The Plan denied your request. The Plan says DRG 417 is not supported as the secondary diagnosis of acute 
respiratory failure with hypoxia (J96.01) is not supported in the medical record. The Plan argues that DRG 418 
is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 417 requires a diagnosis of acute respiratory failure 
with hypoxia (J96.01). 
 
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 inpatient services billed with DRG 417. Our 
reviewer says that the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
record. Our physician reviewer found that diagnosis J96.01 did not meet coding guidelines to qualify for 
reporting. From the information that was received, documentation was inconsistent/unclear regarding a 
diagnosis of acute respiratory failure. Even though acute respiratory failure was documented in the 
postoperative period, supporting medical record documentation was not found within the record. The enrollee 
did develop atelectasis and pleural effusion postoperatively; however, the enrollee did not require extended use 
of high flow oxygen supplementation. Rather, the enrollee only required 1-2 liters of low flow oxygen, 
conflicting with acute respiratory failure. Also, oxygen support is often expected in the postoperative period. 
Further, the enrollee remained in no acute distress and no respiratory distress in the postoperative period, which 
conflicts with acute respiratory failure. The review has determined that the medical records did not support the 
billing of secondary diagnosis acute respiratory failure with hypoxia (J96.01). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services billed with DRG 417 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from October 5, 2020, to 
October 8, 2020, as billed with DRG 417.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on  
September 20, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says 
attempts were made to obtain the explanation of benefits (EOB) for services, but attempts were unsuccessful. 
The Plan has not received an EOB from the primary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an EOB from the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for 
diagnostic radiology services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 15, 2021. 
 
You asked the Plan to pay for drug test. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug test have not been met. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on October 
26, 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 CPT code. 
 
The file shows that CPT code 72193 was billed with code 74160. We find that CPT code 72193 may be eligible 
for payment when billed with this code pair. The claim 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 October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the analysis was critical in determining the 
appropriate course of treatment. The Plan denied your request. The Plan says the services were not urgent, 
emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the lab services at issue in this appeal. 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 the lab services provided on November 12, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 15, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that the specimens received must be processed without 
delay. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. This claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on August 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111) and the administration (96372). 
 
You asked the Plan to pre-approve Evenity and the administration. You say that the enrollee has severe 
osteoporosis and is at very high risk for fracture due to age, low bone mass, and previous fractures. The Plan 
denied your request. The Plan says Evenity is a non-preferred product, and the enrollee does not have any 
stated contraindications to the preferred products. The Plan also says that the enrollee has not tried any of the 
preferred agents.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity and the administration. Our 
reviewer says that Evenity is not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the Plan requires a trial of Forteo before they will approve the requested drug. Our reviewer found that in 
this case, the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is 
no documentation provided indicating that the Plans required drug 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 Evenity and the administration have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Evenity (J3111) and the administration (96372).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 26, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the codes 
remain not supported. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim information was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. 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 drug testing services provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.  
 PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit, and x-rays provided on 
October 20, 2021. 
 
You asked the Plan to pay for the hospital outpatient clinic visit and x-rays. The Plan denied your request. The 
Plan says if the enrollee needs medical care that Medicare requires our Plan to cover, and the providers in our 
network cannot provide this care, the enrollee can get this care from an out-of-network provider. The medical 
care will be coordinated for the enrollee with an out-of-network provider. Prior authorization from our Plan 
must be obtained prior to obtaining services. There are no records of a prior authorization being obtained from 
the members PCP to the Plan. 
 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 the hospital outpatient clinic visit, and x-rays provided on  
October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on October 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that the reports support this procedure was 
performed. The Plan denied your request. The Plan says the documentation does not support an additional 
study. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We 
find that CPT code 71045 is not supported in the medical record. The records show that CPT code 71045 was 
previously billed and paid for by the Plan. The medical records do not show that more than 1 chest x-ray was 
performed on the date of service at issue.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on October 20, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CALR and MPL gene analysis (81218 and 81338) 
provided on August 17, 2021. 
 
You asked the Plan to pay for the CALR and MPL gene analysis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage 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 the CALR and MPL gene analysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee had mild thrombocytosis on previous 
laboratory testing. The record provided is insufficient to establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 CALR and MPL gene analysis have not been met. Therefore, we decided 
that the Plan does not have to pay for the CALR and MPL gene analysis (81218 and 81338) provided on 
August 17, 2021.