Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit, and nail debridement provided on 
September 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that these services do not require authorization. 
You also say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that the enrollee self-directed for care. The Plan also says that 
there is no network deficiency. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the 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 outpatient visit, and nail debridement provided 
on September 20, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of heart, without contrast material, with quantitative evaluation of 
coronary calcium. You say that this is medically necessary. The Plan denied your request. The Plan says 
Medicare does not cover the requested service for screening purposes. 
 
The Plan follows Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service 
and will be denied as not 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 a CT of heart, without contrast material, 
with quantitative evaluation of coronary calcium. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found the documentation indicates that the enrollee is diagnosed with hypertension and 
dyslipidemia. The provider is requesting a computed tomography (CT) coronary calcium score test. Upon 
review of LCD L33559: Quantitative Calcium Scoring is not a covered service and will be denied as not 
medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed 
in association with CT angiography, there is neither separate nor additional included reimbursement for the 
calcium scoring. 
 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 CT of heart, without contrast material, with quantitative evaluation of 
coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium 
(75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you have been bedridden for all of 2023, 
and you need to rehabilitate to be able to be supported. The Plan denied your request. The Plan says you do not 
meet the requirements for admission to an LTACH. 
 
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 that you are currently undergoing treatment at an acute care hospital (ACH), having 
been admitted with peritonitis requiring emergency abdominal surgery.  You were intubated/ventilated, 
subsequently received a tracheotomy, and have since been decannulated. There is no evidence that you require 
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring you to the LTACH.   
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an invasive (Guardian) sensor (A9276) and transmitter 
(A9277) for an interstitial continuous glucose monitoring (CGM) system. 
 
You asked the Plan to pre-approve invasive sensor and transmitter. You say that this type of supply is covered. 
The Plan denied your request. The Plan says these supplies are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies which do not meet the DME benefit 
category requirements, such as A9276 and A9277, will be denied automatically as non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of invasive sensor and transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an invasive (Guardian) sensor (A9276) and transmitter (A9277) for an interstitial 
continuous glucose monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day monitoring system. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the records provided support the necessity 
of the requested service. The Plan denied your request. The Plan says the enrollee is not on insulin and does not 
meet the Medicare criteria 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day monitoring system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure (64628). 
 
You asked the Plan to pre-approve intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
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 intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy drugs provided on September 
6, 2022. 
 
You asked the Plan to waive the cost share for chemotherapy drugs. You say that you met your maximum out-
of-pocket expense. 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 20% 
coinsurance for Medicare Part B chemotherapy drugs.  
 
You have been asked to pay a $2,091.59 coinsurance for chemotherapy drugs ($10,457.95 allowed amount x 20% coinsurance = $2,091.59 coinsurance applied). This item/service falls within the Medicare Part B 
chemotherapy 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 waive the cost share for chemotherapy drugs 
and provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colostomy supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve colostomy supplies from an out-of-network provider. You say that the in-
network provider does not carry the same brand of supplies. The Plan denied your request. The Plan says you 
must receive covered services from contracted providers unless the service is for an emergency or when it is 
medically necessary for you to go out-of-network because a contracted provider is unable to provide you the 
same 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
colostomy supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim should not have been denied for 
no authorization because the patient did not choose the anesthesiologist. The Plan denied your request. The 
Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service September 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for SelectMDx testing provided on August 26, 2022. 
 
You asked the Plan to pay for SelectMDx testing. You say that this testing was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says that the request does not meet the Medicare 
rules because a review of the published literature and clinical practice guidelines does not support this testing 
as a means to determine which men should undergo prostate biopsy. 
 
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 SelectMDx testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that SelectMDx is medically reasonable and necessary for the enrollee in this case. The enrollee 
does not have an established diagnosis of prostate cancer, has not had a prostate biopsy, but is a candidate for a 
prostate biopsy which would potentially impact management. The medical record supports the medical 
necessity of this test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SelectMDx testing have been met. Therefore, we decided that the Plan has to 
pay for SelectMDx testing provided on August 26, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography, bilateral (code 77067) and 
ultrasound examination of the breast (code 76441-RT, 76441-LT) provided on June 20, 2022. 
 
You asked the Plan to pay for screening mammography, bilateral (code 77067) and ultrasound examination of 
the breast (code 76441-RT, 76441-LT). The Plan denied your request. The Plan says this claim is a duplicate of 
a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 13, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for screening mammography, bilateral (code 77067) and ultrasound examination of the breast (code 76441-RT, 76441-LT) have not been met. Therefore, we decided 
that the Plan does not have to pay for screening mammography, bilateral (code 77067) and ultrasound 
examination of the breast (code 76441-RT, 76441-LT) provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI scan provided on December 1, 
2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you should have this copayment waived 
since you need to get this done every year due to a genetic condition. 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 $325 
copayment for Medicare-covered diagnostic radiology services, including MRIs.  
 
You have been asked to pay $280.42, which is less than the standard $325 copayment for the MRI. This 
item/service falls within the outpatient diagnostic tests and therapeutic 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. Therefore, we decided that the Plan 
does not have to waive the copayment for the MRI scan provided on December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not show the enrollee requires the level of care provided 
at an IRF and their needs can be met at a lever level of care like at a skilled nursing facility. 
 
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 that the enrollee is walking at a community level. The enrollee does not require 
intensive rehabilitation and does not require frequent physiatry oversight. 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 the IRF admission and services.
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. The Plan denied your request. The Plan says the enrollee is 
requiring a higher level of rehabilitation services to optimize mobility and strength for returning back to home 
with a safe and sustainable discharge as well as higher level of independence and decrease in caregiver burden. 
 
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 enrollee does not have intensive rehabilitation needs, and chronically ill 
functioning at a home care level. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided and 
the Medicare-approved major drug, there is no indication that the Plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgery to place a Vertiflex Superion device (22869, 
22870). 
 
You asked the Plan to pre-approve a surgery to place a Vertiflex Superion device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 surgery to place a Vertiflex Superion 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this service is considered experimental. 
 
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 surgery to place a Vertiflex Superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a surgery to place a Vertiflex Superion device (22869, 
22870).