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

 
We decided that the Plan does not have to pay for the Urovysion fluorescence in situ hybridization (FISH) 
testing provided on June 18, 2021. 
 
You asked the Plan to pay for the Urovysion FISH testing. You say that this testing is medically necessary and 
should be paid. The Plan denied your request. The Plan says this is considered a noncovered screening test for 
urothelial cancer. 
 
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 Urovysion FISH testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found UroVysion FISH testing is considered experimental/investigational as a 
screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still 
be necessary regardless of the results of UroVysion FISH testing. Urinary biomarker tests such as UroVysion 
FISH testing give significant false-negative results in patients with urothelial cancer and are subject to false-
positive results in others. Accuracy is poor for low-stage and low-grade tumors.    
 
To date, there are multiple urine markers that have improved sensitivity over cytology but there is lack of 
validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial 
diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective 
validations are needed to confirm these findings.  
 
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 Urovysion FISH testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Urovysion fluorescence in situ hybridization (FISH) testing provided on June 
18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pyridostigmine tablets. 
 
You asked the Plan to pre-approve Pyridostigmine tablets. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Pyridostigmine tablets are not covered under the 
enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pyridostigmine tablets.  
 
Benefits for Pyridostigmine tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on July 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says that the claim was not submitted with 
the required diagnosis code. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, there is no governing Local Coverage Determination or Medicare 
language to indicate a required diagnosis code for ambulance services in this state. The Plan has not forwarded 
any additional evidence to support their denial. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor 
Therefore, we decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on July 
19, 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 services provided by an out-of-network provider on 
September 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 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 services provided by an out-of-network provider on 
September 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Dupixent is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) evaluation provided on July 
20, 2021. 
 
You asked the Plan to pay for the ED evaluation. You say that the level of ED services billed is supported by 
the records. The Plan denied your request. The Plan says two claims were submitted for the same code on the 
same date of service. One was denied as duplicate, which is supported by the records that only document a 
single ED evaluation was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims are denied but may be 
appealed.  
 
In this case, review has shown that the claim is a true duplicate as the records do not support that more than one 
evaluation was performed by the physician at issue. The claims history shows that one evaluation was 
reimbursed. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) 
evaluation provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says removal of torus mandibularis is not listed as a covered service 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of torus 
mandibularis are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removal of torus mandibularis (D7473 x 2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia provided to the enrollee on January 5, 2022. 
 
You asked the Plan to pay for the drug. You say that this was tolerated well without any side effects. The Plan 
denied your request. The Plan says the enrollee is not on calcium, and has not failed oral medication. 
 
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 pay for the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is not on 
calcium and has not failed oral medication. The review has determined that the documentation does not support 
that the Prolia is medically reasonable and necessary for the patient. The documentation does not support that 
the Prolia is safe and effective for the patient. 
 
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 pay for Prolia provided to the enrollee on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA of the facet joints in upper back. 
 
 You asked the Plan to pre-approve RFA of the facet joints in upper back. The Plan denied your request. The 
Plan says the requested procedure is supported for no more than two thermal radiofrequency sessions per spinal 
region (cervical/thoracic or lumbar) in 12 months. The clinical information originally provided exceeds this 
limit. Therefore, the requested procedure is not indicated at this time. 
 
The Plan follows Medicare rules. 
 
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 RFA of the facet joints in upper back. 
Our reviewer says that RFA of the facet joints in upper back are not medically reasonable or necessary. Our 
physician reviewer found that the diagnostic blocks did not provide greater than 80% pain relief as required by 
the LCD. Therefore, the request is deemed not medically reasonable or 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 RFA of the facet joints in upper back have not been met. Therefore, we decided 
that the Plan does not have to pre-approve RFA of the facet joints in upper back.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, injection of drug/substance under skin or into 
muscle and injection, garamycin, gentamicin provided on November 1, 2021. 
 
You asked the Plan to pay for an ultrasound, injection of drug/substance under skin or into muscle and 
injection, garamycin, gentamicin. The Plan denied your request. The Plan says the payment was adjusted for 
exceeding precertification / authorization limit and authorization number 3143441. Service is not authorized 
prior to date of service. 
 
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 an ultrasound, injection of drug/substance under 
skin or into muscle and injection, garamycin, gentamicin provided on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on January 9, 2022, billed with code 70450. 
 You asked the Plan to pay for the CT interpretation as billed. You say that the enrollee had multiple exams on 
the date of service. The records support that all codes should be paid as billed. The Plan denied your request. 
The Plan says the Column 2 code was not billed with a required 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 interpretation of the computed tomography (CT) scan of the 
head provided on January 9, 2022, billed with code 70450.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a nerve stimulator implant (63650). 
 
You asked the Plan to pre-approve the nerve stimulator implant. You say that the nerve stimulator is medically 
necessary. The Plan denied your request. The Plan says that the records do not sufficiently support a trial of 
conservative treatment. The implant is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of a nerve stimulator is covered when it 
is used only as a late resort (if not a last resort) for patients with chronic intractable pain. 
 
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 nerve stimulator implant. Our 
reviewer says that the requested implantable stimulator is medically necessary. Our physician reviewer found 
the record shows the enrollee has tried Ibuprofen, Gabapentin, Robaxin, Motrin, and Hydrocodone. She has 
tried Physical Therapy in the past as well as TENS. She has had injections in the past. She had Psychological 
evaluation which cleared her for the implant. Coverage criteria is 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 the nerve stimulator implant have not been met. Therefore, we decided that the 
Plan has to pre-approve a nerve stimulator implant (63650).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 18, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the number of days or units of service exceeds the acceptable maximum. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 23472 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 surgical services 
provided to the enrollee on October 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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's needs are met in the current acute hospital setting. The LTACH does 
not offer any services currently unavailable to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an x-ray examination of the spine, 
lumbosacral (72110) provided on July 15, 2021. 
 
You asked the Plan to reduce the copayment for an x-ray examination of the spine, lumbosacral. You say that 
you received x-rays in the doctor's office, and that you went from the doctor's reception desk to the x-ray room 
in his office. You also say you did not go to the radiology department in the building or to an offsite building, 
and your copayment should be $75, not $101.22. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount. The Plan also says that they called the provider and confirmed the 
enrollee's service was provided in the radiology department, and although there are physician offices in the 
building, there is a separate radiology department in which such services are rendered. The Plan also says that 
they confirmed with the physician's office that they do not have the capability of performing radiology services 
in office. 
 
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 $130 
copayment for x-rays taken at any other location than in a physician's office.   
You have been asked to pay $101.22, which is less than the $130 copayment for an x-ray examination of the 
spine, lumbosacral. An x-ray examination of the spine, lumbosacral falls within the outpatient diagnostic tests 
and therapeutic services and supplies 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 reduce the copayment for 
an x-ray examination of the spine, lumbosacral (72110) provided on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that you have 
trouble checking your blood sugar with finger pricks. The Plan denied your request. The Plan says the 
requirements 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (CPT code J0897) to be provided by a pharmacy. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they confirmed a pharmacy will be supplying this medication and it will not be 
provided via Buy and Bill. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia (CPT code J0897) to be provided by a pharmacy.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.