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

 
We decided that the Plan does not have to pay for an office visit and drug testing provided from December 29, 
2021, to February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and drug testing. You say that you did not know that you had to do 
an appeal within a certain time frame. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that these services were not approved in advance. 
 
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 an office visit and drug testing provided from 
December 29, 2021, to February 23, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower leg prosthesis and associated additions to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve lower leg prosthesis and associated additions. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 
lower leg prosthesis and associated additions to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint x2 (64635) and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint x2 (64636) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested procedure is supported for no more than two thermal 
radiofrequency session per spinal region in 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. This request is for four (4) radiofrequency sessions, which exceeds 
the benefit limit. 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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet 
joint x2 (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, each additional facet joint x2 (64636) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand of diabetic supplies. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee prefers the requested brand. 
The Plan denied your request. The Plan says there is no rationale why the preferred strips are not able to be 
used. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred.  
 
 
 The requested brand is not preferred with the Plan. The Plan has a preferred brand 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 non-preferred brand of diabetic supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that this equipment is 
medically necessary for your condition. The Plan denied your request. The Plan says this item is not covered 
according to Medicare coverage rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 77002. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 77002 is bundled into 
payment for code 20611. 
 
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 77002 
is a column II code to column I code 20611. 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 procedure code 77002 billed for date of service May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the laser surgery provided on May 13, 
2022. 
 
You asked the Plan to reduce the copayment for the laser surgery. You say that the copayment is very high. 
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 $350 
copayment for Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay a $350 copayment for the laser surgery. This item/service falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 the laser surgery provided 
on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62323). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the provider is appealing the 
medical necessity denial for epidural steroid injections, due to radiculopathy, lumbar region. The Plan denied 
your request. The Plan says epidural steroid injections are considered medically reasonable and necessary when 
the requirements are met. However, based on the clinical received from the provider, not all requirements from 
the Local Coverage Determination (LCD) were 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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has numbness/tingling to top of right foot, no weakness. The 
enrollee denies bowel/bladder incontinence. The enrollee manages pain with Oxycodone (10mg 4 times daily 
as needed). She is s/p right and left lateral branch ablation, which provided > 50% pain relief for > 1 year. 
According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis 
and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies 
completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain.  
Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 5, 2021, through 
October 11, 2021, at DRG 682. 
 
You asked the Plan to pay for inpatient services at DRG 682. You say that review of the medical records 
supports the presence of clinical indicators, risk factors, treatment and consistent documentation for acute 
kidney failure. The Plan denied your request. The Plan says principal diagnosis code N17.9 is not supported. 
 
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 diagnosis code N17.9, defined as acute renal failure, 
unspecified. 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 inpatient services at DRG 682. Our 
reviewer says that the documentation does not support the principal diagnosis of acute renal failure. Our 
physician reviewer found that acute renal failure is defined as a creatine rise of 1.5 above baseline or a rise of 
0.3 within 48 hours. There was no documented rise in creatine sufficient to meet the criteria for this diagnosis  
 
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 services provided from October 5, 2021, through October 11, 2021, at DRG 682.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2021, billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, 
and 81194. 
 
You asked the Plan to pay for the genetic testing billed. 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 must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 30, 2021, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 
81301, 81311, 81317, 81321, and 81194.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is very high functioning at baseline and 
the potential for him to return to his prior level of function will be optimized only with this high intensity 
rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 was admitted for thrombectomy of an arterial occlusion in the leg, 
fasciotomy, and treatment of atrial fibrillation. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing 
provided April 10, 2022. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing. You say that these 
tests were medically necessary. The Plan denied your request. The Plan says this test was billed with the wrong 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT and Heme CGP Panel testing are 
not FDA approved. Based on this information, we decided that Medicare rules for coverage of the requested 
testing have not been met. Based on this information, we decided that Medicare rules for coverage of the 
Tempus xT Solid Tumor and Heme CGP Panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing provided April 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of an 
osteoporosis-related fracture or that the enrollee has tried and failed or has a contraindication to zoledronic 
acid. The documentation does not support that zoledronic acid would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed and related accessories (E0305, 
E0295, E0271, E0185). 
 
You asked the Plan to pre-approve a semi-electric hospital bed and related accessories. You say that the 
enrollee requires assistance with his activities of daily living, including reminders and verbal cuing to follow 
through on tasks. He has mobility impairments and is at risk for falls. Due to his medical condition, it is 
recommended that he receive a semi- electric hospital bed. This will allow him to have frequent changes in 
body position to help alleviate pain and to allow for safe transfers. The Plan denied your request. The Plan says 
that the enrollee is able to shift and move himself in his bed as needed. This request does not meet coverage 
criteria. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed and related 
accessories. Our reviewer says that the service is medically necessary. Our physician reviewer found clinical 
documentation shows that the enrollee has spasticity related to CVA and requires frequent changes in body 
position that would not be allotted without a semi-electric hospital bed. In addition, the enrollee has functional 
impairments and would require positions of body that would not be feasible without semi-electric hospital bed 
for safe transfers. 
 
 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 semi-electric hospital bed and related accessories have been met. Therefore, 
we decided that the Plan has to pre-approve a semi-electric hospital bed and related accessories (E0305, E0295, 
E0271, E0185).  
 
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 PrismRA testing provided on April 5, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered for the indications established in the 
applicable NCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
NCD criteria requires the test be FDA-approved. The PrismRA is not FDA-approved. Therefore, the requested 
testing is not medically necessary according to the coverage criteria in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA testing provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on February 1, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that record shows presumptive screening test results which are partially inconsistent with prescription 
medications, or history and expected results. Definitive confirmation testing was medically necessary for only 
1 drug class. The requested definitive drug testing of 22 or more drug classes was 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 the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on February 1, 2022.