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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 17, 2020. 
 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on July 17, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says that based on the medical records, Medicare coverage criteria are not 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 Plan did not provide medical records 
to support its denial. Our physician reviewer found the limited medical records in the file do not support the 
Plans denial of services as stated in their review. 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 been met. The 
Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the 
service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided 
that the Plan has to pre-approve skilled nursing facility (SNF) care.  
 
 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve donepezil (Aricept). 
 
You asked the Plan to pre-approve donepezil. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 donepezil (Aricept).  
 Benefits for donepezil 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve endobronchial valve (EBV) placement via bronchoscopy 
procedure. 
 
You asked the Plan to pre-approve EBV placement via bronchoscopy. You say that the requested procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says that there is not enough 
evidence this this procedure has better long-term health outcomes. 
 
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 EBV placement via bronchoscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found EBV placement via bronchoscopy is considered medically necessary for this 
patient.  EBV is a way of inducing "lung reduction" and reducing air trapping in patients with severe 
emphysema. The effect is similar to surgical lung reduction, but with less morbidity because it is less invasive.  
Several sham-controlled clinical trials have established the risks and benefits and follow up beyond 5 years has 
shown persistence of benefits and absence of unanticipated long-term risks. There is a substantial risk of 
pneumothorax in the first few days after the procedure, so inpatient hospital stay is necessary following the 
procedure. This procedure is no longer considered experimental in the pulmonary community for patients that 
meet established criteria. This patient meets all clinical criteria for the procedure. The denial is reversed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EBV placement via bronchoscopy have been met. Therefore, we decided that 
the Plan has to pre-approve endobronchial valve (EBV) placement via bronchoscopy procedure.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to LTACH for a multi-
disciplinary approach to care to promote optimal recovery and regain maximum functioning. The Plan denied 
your request. The Plan says authorization denied because criteria for LTACH admission have 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 records show the enrollee is receiving appropriate care at the present acute care 
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850 (J7320). 
 
You asked the Plan to pre-approve GenVisc 850. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc, 
Synvisc, and Synvisc One. 
 
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 GenVisc 850. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found he provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria have not been 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 GenVisc 850 have not been met. Specifically, the file does not show that the 
enrollee has tried and failed the step one alternatives. Therefore, we decided that the Plan does not have to pre-
approve GenVisc 850 (J7320).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 9, 
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 provider did not bill as required by Medicare coding regulations. 
 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 imaging services provided to the enrollee on November 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that this provider can come to your home 
to provide the physical therapy services. The Plan denied your request. The Plan says you must receive care 
from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of 
the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the Plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the implanted neurostimulator analysis (95972) provided by on 
September 29, 2021. 
 
You asked the Plan to pay for the implanted neurostimulator analysis (95972). You say that CPT code 95972 
describes the further electronic calibration, analysis and monitoring for pain relief. You say that CPT code 
95972 should be separately payable and should be reprocessed on its own merits. The Plan denied your request. 
The Plan says that CPT code 95972 is considered inclusive to CPT code 63650. 
 
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 95972 is electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact 
group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose 
lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop 
parameters, and passive parameters) by physician or other qualified health care professional; with complex 
spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by 
physician or other qualified health care professional. 
 
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 implanted neurostimulator analysis (95972). Our 
reviewer says that the documentation submitted was reviewed and does meet the criteria for coverage. Our 
reviewer found that the operative report describes placement of a permanent neurotransmitter, the enrollee was 
then transferred to recovery and the analysis was performed. No documentation was found to support the 
analysis cannot be performed after implantation and the modifier would be appropriate. 
 
  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 implanted neurostimulator analysis (95972) have been met. Therefore, we 
decided that the Plan has to pay for the implanted neurostimulator analysis (95972) provided by on September 
29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira Pen injection. 
 
You asked the Plan to pre-approve a Humira Pen injection. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says a Humira Pen injection 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 a Humira Pen injection.  
 Benefits for a Humira Pen injection 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urology office visit (99213) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the urology office visit. You say that this service is medically necessary. 
The Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a urology 
office visit (99213) to be provided by an out-of-network (OON) provider.
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 enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says IRF is not medically necessary, and the enrollee's needs can be met at 
a lower level of care such as SNF. 
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is not a reasonable expectation that this enrollee would 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CustomNext-Cardio, CardioNext, and TAADNext 
genetic testing. 
 
You asked the Plan to pre-approve CustomNext-Cardio, CardioNext, and TAADNext genetic testing. You say 
that the requested CustomNext-Cardio, CardioNext, and TAADNext genetic testing is medically necessary. 
The Plan denied your request. The Plan says the requested CustomNext-Cardio, CardioNext, and TAADNext 
genetic testing 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 CustomNext-Cardio, CardioNext, and 
TAADNext genetic testing. Our reviewer says that the requested CustomNext-Cardio, CardioNext, and 
TAADNext genetic testing is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has a history of heart disease. The record provided does not indicate how the requested testing 
would alter the enrollee's clinical management. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CustomNext-Cardio, CardioNext, and TAADNext genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve CustomNext-Cardio, CardioNext, and 
TAADNext genetic testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility. 
 
You asked the Plan to pre-approve the admission. 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 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing 
services. The specialized skill, knowledge, and judgement of a skilled professional nurse are not required to 
safely and effectively provide medically necessary and reasonable treatment. The documentation does not 
support that it is medically reasonable and necessary to provide these skilled nursing or skilled therapy services 
(or a combination of these services) on a "daily basis" on an inpatient basis, in a skilled nursing facility setting. 
The goal of an IRF stay is to allow a patient to return safely to home or to a community-based environment 
upon discharge. The services required are offered at the inpatient rehabilitation facility. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening provided on 
October 26, 2021. 
 
You asked the Plan to pay for the abdominal aortic aneurysm screening. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says you previously had this 
screening on June 17, 2016. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Per your benefits in the 2021 EOC, you can only get an abdominal 
aortic aneurysm screening performed one-time (once per lifetime). You previously received an abdominal 
aortic aneurysm screening on June 17, 2016; therefore, the claim for date of service October 26, 2021, denied 
correctly and you are responsible for the full cost of the abdominal aortic aneurysm screening. Therefore, we decided that the Plan does not have to pay for the abdominal aortic aneurysm screening provided 
on October 26, 2021.