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

 
We decided that the Plan has to pay for Allosure genetic testing (81479) provided from December 17, 2021, to 
June 20, 2022. 
 
You asked the Plan to pay for Allosure genetic testing. You say that the services at issue were a medical 
necessity for you. The Plan denied your request. The Plan says that the services at issue were not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that AlloSure Kidney is covered to assess the 
probability of allograft rejection in kidney transplant recipients with clinical suspicion of rejection and to 
inform clinical decision-making about the necessity of renal biopsy in such patients at least 2 weeks post-
transplant in conjunction with standard clinical assessment. 
 
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 Allosure genetic testing. Our reviewer says 
that the services at issue are considered medically reasonable and necessary in this case. Our physician 
reviewer found that, since the goal of the provider is to keep tacrolimus levels low (3-5), it is reasonable and 
appropriate to use Allosure genetic testing by protocol. Morbidity and mortality associated with transplant 
failure is quite high, and biopsy is risky and costly to perform in surveillance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Allosure genetic testing have been met. Therefore, we decided that the Plan has 
to pay for Allosure genetic testing (81479) provided from December 17, 2021, to June 20, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drug, oral iron. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Feraheme is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that Neulasta is 
indicated for moderate to high risk of neutropenic fever. Based on the proposed regimen of Carboplatin, 
Pemetrexed, and Pembrolizumab and the lack of high-risk patient factors Neulasta would not be indicated. The 
service is not reasonable or medically indicated.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography of the lower extremity provided to the 
enrollee on July 6, 2022. 
 
You asked the Plan to pay for the services. You say that the services are not bundled or inclusive and are 
separate and distinct. The Plan denied your request. The Plan says the diagnosis codes associated to CPT 73700 
are mismatched to the procedure modifier. 
 
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 73700 is "Computed tomography, lower extremity; 
without contrast material." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records include a 
radiological report for "CT knee left without contrast" for concern tibial plate fracture at knee. The radiological 
report confirms a left knee fracture. In this case, diagnosis was not reported to the highest specificity, as there is 
a more appropriate code to report for left knee fracture.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography of the lower extremity provided to the enrollee on July 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require daily skilled therapy and is functioning at a home care 
level. She does not have daily skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee could be hospitalized without the 
equipment. The Plan denied your request. The Plan says the enrollee's needs can be met with a different device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has COPD, but there are no pulmonary function tests to confirm and assess severity.  
The appeal indicates a partial pressure carbon dioxide (PaCO2) of 62, but complete results, and the 
circumstances, are not provided. If this enrollee does have chronic CO2 retention, documented on arterial blood 
gas (ABG) done while stable, may benefit from BiPAP. There is no documentation that this has been tried and 
failed as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. Therefore, the request 
is not medically necessary.  
 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve K3 components for a prosthesis (L5981, L5986). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request can be overturned except for the K3 components, as the records do not 
support this level of functional status. 
 
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 services. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the requested K3 components are not medically necessary as the documentation doesn't 
support that the enrollee is expected to be able to ambulate at a K3 level. The provider has noted that the 
enrollee is expected to require K2 level prosthesis with dynamic feet. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve K3 components for a prosthesis (L5981, L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. More research is needed. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a penile prosthesis and implant. 
 
You asked the Plan to pre-approve a penile prosthesis and implant. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have 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 a penile prosthesis and implant. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found a penile prosthesis/implant is not medically reasonable and necessary in 
this case. Penile prosthesis implant surgery is a well-established option for the treatment of erectile dysfunction 
according to the current AUA guidelines. However, treatment with a penile prosthesis is usually undertaken if 
there has been failure or intolerance to other treatments such as oral medications (Viagra, Cialis, Levitra), 
vacuum erection devices, penile injections (Edex, Caverject), or urethral suppositories (Muse). In this case, the 
records do not show that the enrollee has received any prior 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 a penile prosthesis and implant have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a penile prosthesis and implant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. 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. 
 
The Plan follows Medicare rules. Medicare rules say that ESA treatment is covered under certain 
circumstances. 
 
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 
services are not medically necessary. Our physician reviewer found the accepted use of this drug for the 
enrollee's condition requires iron status has been evaluated and sufficient iron levels will be maintained prior to 
initiation of therapy and continuation of therapy (i.e. transferrin saturation should be at least 20% OR ferritin at 
least 100ng/ml). In this case, the enrollee has inadequate iron stores. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 Retacrit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehab provided on July 29, 2022, to 
August 26, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehab. You say that you shouldnt have to pay for this. 
The Plan denied your request. The Plan says this cost sharing was charged 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 a $35 
copayment for Cardiac rehabilitation services. 
 
You have been asked to pay a $35 copayment for cardiac rehab. This item/service falls within the Cardiac 
rehabilitation services 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. You have been asked to pay $420 ($35 x 12 visits) copayment for your cardiac rehab. 
Therefore, we decided that the Plan does not have to waive the copayment for cardiac rehab provided on July 
29, 2022, to August 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of spinal instability. There is no documentation of adequate 
conservative measures to include recent physical therapy for low back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 19, 2022, to June 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services provided on April 19, 2022, to 
June 2, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 15, 2021, to 
May 19, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
inpatient hospital services as billed is supported in the medical record. The Plan denied your request. The Plan 
says the documentation does not support the inpatient care as billed. 
 
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.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as acute 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis code as billed. Our physician reviewer found that the documentation indicates that the 
member was admitted to the hospital with shortness of breath due to acute pulmonary embolism. An arterial 
blood gas was not performed. The oxygen saturation was 93% on room air on presentation. It is noted that the 
oxygen saturation dropped to 90% which improved to 93-95% on 2-4 liters nasal cannula oxygen in the 
emergency department. The oxygen saturation was 92-95% on room air during the hospital stay. However, 
there was no documentation of persistent respiratory distress/increased work of breathing, persistent tachypnea, 
cyanosis, or persistent or progressive dyspnea over the member's baseline. The physician documented in the 
history and physical and progress notes "no acute distress." Listing of acute respiratory failure with hypoxia in 
the medical record was not supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 15, 2021, to May 19, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 25, 2021. 
 
You asked the Plan to pay for the ambulance services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says this claim has to be processed by the primary 
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 identified the 
primary payer and it appears as though you attempted to file a claim with them.  The primary payer denied 
payment because they needed additional information from you.  It appears as though you have not yet 
responded to their requests for additional information.  As a result, the claims process at the primary level has 
not been completed.  You must submit whatever documentation the primary insurer requested of you.  After 
that is done, if the primary insurer still denies your claim, you may have the right to submit to the Plan as the 
secondary insurer, but not yet.. As the secondary insurer, the Plan cannot be held responsible for the ambulance 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on June 25, 2021.