Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Ilumya. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Remicade, Inflectra OR Infliximab would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97112, 97116, 97530) 
provided on August 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON therapy. You say that these services were necessary and should be covered. 
The Plan denied your request. The Plan says out-of-network care is only covered in certain limited 
circumstances. The requested services were not urgent or emergent, nor were they pre-approved. 
 
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 physical therapy services (97112, 97116, 
97530) provided on August 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physician Visit provided on February 8, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Physician 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 it was 
determined these services were not urgent or emergent. 
 
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 Physician Visit provided on February 8, 2022 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement. 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered investigational. More research is needed to show 
safety and efficacy. 
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the DME purchased on January 21, 2021, from a 
provider not contractor by Medicare. 
 
You asked the Plan to reimburse for the DME. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME have not been met. This store is not a Medicare 
contracted DME provider. The Plan only covers the DME purchase if the DME supplier is enrolled in 
Medicare. Therefore, we decided that the Plan does not have to reimburse for the DME purchased on January 
21, 2021, from a provider not contractor by Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are a new amputee, and the doctor feels you are 
unsafe to discharge to skilled nursing facility (SNF). You state appropriate care for a new amputee at this time 
is inpatient rehabilitation and SNF is not knowledgeable to assist with a new amputee. The Plan denied your 
request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 4, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that referrals are not necessary for the service 
that was provided, and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a specialist office visit provided on January 4, 
2022, by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on December 23, 2021. 
 
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. 
The Plan says that the records show that only 18 drug classes were tested. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that more than 
22 drug classes were tested. The classes tested include alkaloids, not otherwise specified; amphetamines ; 
antidepressants, serotonergic class; antidepressants, tricyclic and other cyclicals; barbituates; benzodizepines; 
buprenorphine; cannabinoids, natural; cannabinoids, synthetic; cocaine; fentanyls; gabapentin, non-blood; 
heroin metabolite; ketamine and norketamine; methadone; methylenedioxyamphetamines; opiates; opioids and 
opiate analogs; oxycodone; pregabalin; sedative hypnotics (non-benzodiazepines); skeletal muscle relaxants; 
tapentadol; and tramadol. Based on this information, we decided that Medicare rules for coverage of drug 
testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on 
December 23, 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 urine cytopathology (88120) provided September 14, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. Procedure 
code 88120 has not met the associated diagnosis code relationship criteria. 
 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 88120 is cytopathology, in situ hybridization (eg, FISH), 
urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen.  
 
We find that CPT code 88120 is not supported in the medical record. Specifically, 88120 is not a Medicare 
benefit for the diagnosis listed on the claim (R31.29-other microscopic hematuria) and is done for screening 
purposes. Bladder cancer tumor markers performed by any technology immunoassay, molecular or FISH 
testing, are not covered for screening of all patients with hematuria. Bladder tumor markers are not expected to 
be performed until other diagnostic studies fail to identify the etiology of the hematuria. Urine cytology is not 
considered a bladder tumor marker. Based on this information, we decided that Medicare rules for coverage of 
the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the urine 
cytopathology (88120) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living facility (ALF) visit provided on November 
10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ALF visit. You say that it is the responsibility of the ALF to obtain 
prior authorization. These services should be covered due to medical necessity. The Plan denied your request. 
The Plan says these OON services were not emergent/urgently needed. No authorization for OON care was 
obtained. The claim was correctly denied. 
 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 assisted living facility (ALF) visit provided on 
November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on January 6, 
2022, and January 7, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that these services were billed correctly and 
are supported in the record. The Plan denied your request. The Plan says these services are not supported in the 
record. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 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 subsequent hospital care. Our reviewer says that the Plan's 
denial is correct in this case. Our reviewer found the documentation does not support CPT code 99233 for the 
dates in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for subsequent hospital care (99233) provided on January 6, 2022, and January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the bevacizumab-awwb (Q5107) and 
chemotherapy infusion (96413) provided on March 25, 2021. 
 
You asked the Plan to pay an additional amount for the chemotherapy services. You say that the services 
should be covered in full. You also say that you have paid the full out of pocket amount for the year. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for the chemotherapy services. The chemotherapy services fall within the Medicare Part B prescription drugs benefit category. 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 pay an additional 
amount for the bevacizumab-awwb (Q5107) and chemotherapy infusion (96413) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography guidance for placement of radiation therapy 
fields. 
 
You asked the Plan to pre-approve computed tomography guidance for placement of radiation therapy fields. 
You say that the patient has a pacemaker and must have Image-guided radiation therapy (IGRT). The Plan 
denied your request. The Plan says that the pacemaker and target volume can be aligned safely/precisely on a 
daily basis with the use of standard portal IGRT has not been shown to improve clinical outcomes in the 
member's setting, nor is it required for safe/effective. 
 
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 computed tomography guidance for 
placement of radiation therapy fields. Our reviewer says that the requested computed tomography guidance for 
placement of radiation therapy fields is considered medically reasonable and necessary in this case. Our 
physician reviewer found it is plausible that with this enrollees obesity (BMI ~50) and with an exam 
describing pendulous breasts, IGRT would be necessary as daily set up can potentially be compromised 
without IGRT. As there is a plausible benefit and this enrollees anatomy being exceptional, IGRT would be 
furnished in accordance with accepted standards 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 computed tomography guidance for placement of radiation therapy fields have 
been met. Therefore, we decided that the Plan has to pre-approve computed tomography guidance for 
placement of radiation therapy fields (77014).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on December 1, 2021, by an 
OON provider. 
  You asked the Plan to pay for the therapy services. You say that it was medically necessary to provide 
treatment to the enrollee and you would like the claim to be reprocessed for payment. The Plan denied your 
request. The Plan says the rendering and referring providers are both OON providers and there was no 
approved authorization. 
 
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 therapy services provided on December 1, 
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LiteTouch lancets. 
 
You asked the Plan to pre-approve the LiteTouch lancets. You say that the lancets are medically necessary. The 
Plan denied your request. The Plan says this brand is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The plan covers Lifescan and Abbott brand diabetic testing supplies. 
LiteTouch is not one of these brands. Based on this information, we decided that Medicare rules for coverage 
of the LiteTouch lancets have not been met. Therefore, we decided that the Plan does not have to pre-approve 
LiteTouch lancets.