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

 
We decided that the Plan does not have to pay for the lab services provided on November 2, 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 providers must report services correctly. 
Providers must report services with the appropriate code.  In this case, we have confirmed that codes 87481, 87640, and 87653 are column II codes to column I code 
87801. These services have not been billed with an appropriate modifier to bypass the edit. We also find that 
the billed 3 units of CPT code 87801 are not supported in the medical records. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on November 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not meet criteria for Retacrit. 
 
The Plan follows Medicare rules. Medicare rules state that erythropoiesis stimulating agents (ESAs) such as 
Retacrit may be covered for Food & Drug Administration (FDA) label indications and some off-label 
indications. 
 
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 Retacrit. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Retacrit. Our physician reviewer found the Food & Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
approved drug compendia do not contain a supporting citation for the requested use of Retacrit in the enrollee's 
clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that a repeat epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says a repeat epidural steroid injection 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that prior epidural steroid injections must provide 
adequate and sustained relief of at least 50% for at least 3 months.  
 
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 repeat epidural steroid injection. Our 
reviewer says that a repeat epidural steroid injection is not medically necessary. Our physician reviewer found 
that in this case, the enrollee has a history of multiple ESIs with mixed responses. The review has determined 
that a repeat epidural steroid injection does not meet the Medicare LCD coverage criteria. 
 
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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 18, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not 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 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 lab services provided on February 18, 2022 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an office visit provided on April 1, 2022. 
 
You asked the Plan to reduce the copayment for an office visit. You say that your primary care physician 
suggested that you go to the urgent care facility, so you believe you should only be charged the $10 primary 
care copayment. The Plan denied your request. The Plan says that the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $10 copayment for each covered visit or consultation in an 
outpatient location with your PCP or other primary care provider. The service was billed as an office visit 
location, and not specified as an urgent care facility. 
 
The Plan says you must pay a $40 copayment for a specialist office visit. Based on the Plan contract, however, 
you cannot be asked to pay more than a $10 copayment for your office visit. Therefore, we decided that the 
Plan has to reduce the copayment for an office visit provided on April 1, 2022.  
 
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 blood count; complete (CBC) (85025) provided on 
March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CBC. You say that you cannot afford the bill. The Plan denied your request. 
The Plan says the referring physician and rendering provider are OON. 
 
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 blood count; complete (CBC) (85025) 
provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve meals, per diem, not otherwise specified (S9977). 
 
You asked the Plan to pre-approve meals, per diem. You say that you have been diagnosed as pre-diabetic for 
many years. Your most recent labs from December 2021, can confirm this. You are requesting reconsideration 
for the requested meals. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
The plan was unable to verify that you have any of the health conditions that would qualify you for the benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of meals, per diem have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve meals, per diem, not otherwise specified (S9977).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor (CGM).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatment (98941) provided on  
February 21, 2022 and February 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided in this case are not 
payable as they were not medically necessary. 
 
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. Additionally, the rules say that coverage of a chiropractic service is specifically limited to treatment 
by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are 
hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in 
performing manual manipulation of the spine.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan was required to obtain the medical records from the 
chiropractor in order to determine whether these treatments met medical necessity criteria. Since no records 
were obtained, the Plan has not supported the denial of payment for these services. Additionally, the use of an 
activator by the chiropractor in this case does not preclude coverage of manual manipulation of the spine as it is 
allowed per Medicare rules. Therefore, we decided that the Plan has to pay for the chiropractic manipulative 
treatment (98941) provided on February 21, 2022 and February 28, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for the SelectMDx urine based prostate cancer screening test provided on 
May 18, 2022. 
 
You asked the Plan to pay for the SelectMDx urine based prostate cancer screening test. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says that the services rendered were 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 pay for the SelectMDx urine based prostate cancer 
screening test. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found emerging prostate cancer molecular biomarkers noted in 
this review are beginning to play an important role in improving diagnosis and treatment. The good news is that 
there is already a promising collection of biomarkers; however, there is also a real challenge for clinicians and 
reimbursing agencies on how to assess and prioritize the new markers. These biomarkers have the potential to 
help clinicians in determining a need for biopsy, especially in patients with prostate-specific antigen (PSA) 
levels in a gray zone of 4.0 to 10.0 ng/mL, thus avoiding unnecessary biopsies. These biomarkers may also 
play an important role in distinguishing clinically significant prostate cancer, thereby determining the treatment 
regime. In this case, the enrollee's PSA is 5.64. Therefore, the enrollee met criteria for the services rendered. 
 
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38985 to support their 
denial. However, LCD L38985 is not valid for the provider's billing state of California. Therefore, we cannot 
use this LCD to substantiate our decision. 
 
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 SelectMDx urine based prostate cancer screening test have been met. 
Therefore, we decided that the Plan has to pay for the SelectMDx urine based prostate cancer screening test 
provided on May 18, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
of this decision for reconsideration. The Plan denied your request. The Plan says based on Medicare guidelines 
and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. 
 
 
 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 the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the record does not include a psychological evaluation documenting that they are suitable for a spinal 
cord stimulator. 
 
The Plan follows Medicare rules. Medicare rules state that insertion of a spinal cord stimulator is only covered 
after certain criteria have been 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer 
found the documentation does not include evidence and results of a formal psychological evaluation as required 
by Medicare criteria to show that the enrollee is appropriate for this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 You asked the Plan to pre-approve additional acupuncture visits. You say that additional acupuncture visits are 
medically necessary. The Plan denied your request. The Plan says a six-month wait period is medically 
necessary before acupuncture services should be resumed. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
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 acupuncture visits. Our 
reviewer says that the requested acupuncture services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is requesting acupuncture treatment for chronic knee pain. The review 
indicates that acupuncture is typically provided only for the treatment of nausea or as part of a comprehensive 
pain management program for the treatment of chronic pain. The requested acupuncture is denied because it is 
not medical necessary based on review of records and available information. The Plan acupuncture clinics do 
not do maintenance or long-term treatment. The review has determined that the requested services are not 
medically necessary or reasonable. 
 
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 acupuncture visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional acupuncture visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses received on January 27, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for contact lenses. You say that you were not aware that the provider was out-of-
network, The Plan denied your request. The Plan says services obtained out-of-network are not covered.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are received from a network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
contact lenses received on January 27, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group. You also say that the rendering physician depends upon the hospital staff 
to verify eligibility and to obtain the proper authorization from the patient's insurance company. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
 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 subsequent nursing facility care provided on 
February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014) provided on January 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an eye examination. You say that a provider performing services in a nursing 
home facility is not responsible to obtain authorization. The Plan denied your request. The Plan says the 
services are not covered because they were not pre-authorized. 
 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 eye examination (92014) provided on January 
20, 2022, by an out-of-network (OON) provider.