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

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided on 
August 31, 2021, and September 14, 2021. 
 
You asked the Plan to waive the copayments for ER visits. You say that it was not your fault you needed to go 
to the emergency room. You also say you needed to go because of a previous surgery. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $120 
copayment for each emergency room visit.  
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a $120 copayment for each ER visit on August 31, 2021, and September 14, 2021. You have been asked to pay a total of $240 ($120 copayment + $120 copayment = $240). An ER visit falls within the Emergency Care 
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 copayments for emergency room (ER) visits 
provided on August 31, 2021, and September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77063, 77067) provided on December 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded.  
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 codes 77063 and 77067 is 1. The MAI value for these codes is 2. You billed 2 
units of each of these codes, 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 the 
services (77063, 77067) provided on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus 648 gene panel provided on August 9, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says there is no rationale given for this testing, and UpToDate does not 
recommend this for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The records submitted show that the enrollee was last seen by the 
ordering provider in September 2019. No records from around the time that this bone marrow sample was 
collected were included. As such, it cannot be determined that the testing was ordered for a specific medical 
problem and that the physician will use the results in patient management. Based on this information, we 
decided that Medicare rules for coverage of the Tempus gene panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the Tempus 648 gene panel provided on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor or 
distribution of radiopharmaceutical agent(s) tomographic (SPECT) (78830). 
 
You asked the Plan to pre-approve the diagnostic service. You say that it is crucial that the enrollee undergo 
SPECT to confirm diagnosis, prognosis and treatment regimen. The Plan denied your request. The Plan says 
the services requested do not meet medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the diagnostic service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in general SPECT scans are reserved for those patients with more indeterminate 
presentations and/or those cases where there is a need to differentiate between overlapping diagnoses. In this 
case, the enrollee is not noted to have such a presentation. Rather, her presentation is "straightforward" so to 
speak. In as much the requested service can be said to otherwise exceed the enrollee's clinical needs at this 
time. This would not meet the Medicare definition of medical necessity. 
 
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 diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiopharmaceutical localization of tumor or distribution of radiopharmaceutical 
agent(s) tomographic (SPECT) (78830).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (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 you appear to be more stable and improving and should only require short-term additional services that can safely be completed at the current facility until you are appropriate for a lower level of care. You do not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.
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 admission to a long term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Crutches provided on March 5, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for Crutches. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
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 Crutches provided on March 5, 2022 by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of bone marrow aspirate during an approved lumbar 
fusion surgery. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that it is felt that the requested services 
should be approved. The Plan denied your request. The Plan says the surgery has been approved; however, use 
of bone marrow aspirate is not proven safe/effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested bone marrow aspirate used during lumbar spinal 
fusion was denied, in this case, is 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of bone marrow aspirate during an approved lumbar fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions (64636 x1). 
 
You asked the Plan to pre-approve facet joint interventions. The Plan denied your request. The Plan says facet 
joint interventions (64636 x1) are not medically necessary. 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who meet both of the following criteria: 
The patient meets the criteria for the first diagnostic procedure; and after the first diagnostic facet joint 
procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the 
duration of relief being consistent with the agent used). 
 
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 facet joint interventions (64636 x1). 
Our reviewer says that facet joint interventions (64636 x1) are not medically necessary. Our physician reviewer 
found that the enrollee is an 84-year-old male with chronic lumbar pain and right buttock/posterior leg pain. He 
reports difficulty walking and bilateral numbness in his legs and feet. He continues to have pain that limits all 
of his daily activities. His pain worsens with standing for any length of time. An MRI of the lumbar spine 
shows severe multi-level degenerative disc disease from L3-S1 greatest with significant foraminal stenosis. 
Clinical notes indicate that the enrollee had two prior facet joint injections with "excellent temporary 
relief." His provider has recommended right L3L4, L4-L5, and L5-S1 radiofrequency ablations (RFAs). In this 
case, the member has chronic axial lumbar pain, pain that interferes with activities of daily living, and prior 
facet joint injections with "excellent pain relief." However, there is no confirmation that the two medial branch 
blocks (MBB) provided at least 80% improvement of the enrollee's pain for the amount of time the numbing 
agent was supposed to last. The review has determined that the requested procedure does not meet the 
Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions (64636 x1) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint interventions (64636 x1).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-one (21) surgical tooth extractions (D7210) for 
tooth #2, #4, #5, #6, #7, #8, #10, #11, #12, #14, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28 and #29. 
 
You asked the Plan to pre-approve tooth extractions. You say that you have had health issues for years with 
several physicians recommending the teeth be extracted to avoid further complications with diabetes and a 
compromised immune system. You cannot drink cold beverages or chew due to tooth pain. You are constantly 
bleeding and have bad breath due to the rotting of your gums. You also say this is medically necessary. The 
Plan denied your request. The Plan says your benefit has been exhausted for the 2022 plan year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two (2) teeth 
extractions per calendar year.  
 
We looked at the file and Medicare rules. The records show you were approved for two (2) tooth extractions on 
May 9, 2022. The EOC confirms you receive 2 extractions per calendar year; therefore, you have exhausted 
your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage 
of tooth extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve 
twenty-one (21) surgical tooth extractions (D7210) for tooth #2, #4, #5, #6, #7, #8, #10, #11, #12, #14, #19, 
#20, #21, #22, #23, #24, #25, #26, #27, #28 and #29.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 4, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to have a COVID 
test and didn't even get out of the car. The Plan denied your request. The Plan says the copayment was applied 
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 $50 
copayment for Medicare-covered urgently needed care when services are provided at an urgent care center.  
 
You have been asked to pay $50 for an urgent care visit. An urgent care visit falls within the Urgently needed 
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 urgent care visit 
provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate procedure. 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no specific indication provided to support the request for bone 
marrow aspirate for the approved surgery. There is a lack of large volume, long-term, peer-reviewed outcome 
studies to support the use of bone marrow aspirate for this enrollees medical condition. 
 
 
 
 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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone marrow aspirate procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve the Eylea. You say that Eylea is medically necessary. The Plan denied your 
request. The Plan says a trial of Avastin is required before alternatives like Eylea can be considered. 
 
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 the Eylea. Our reviewer says that Eylea 
is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drug or any reason it would be unsafe or ineffective. 
 
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 Eylea have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Eylea (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries provided on August 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan, and they have also determined that these services are not 
urgent or emergent, nor were they 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 limited bilateral noninvasive physiologic studies 
of upper or lower extremity arteries provided on August 20, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plasmapheresis for the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that plasmapheresis is only covered for certain 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has been treated with rituximab and monthly steroids as well as pyridostigmine with stable 
symptoms but reported recently "a little worse." He reported benefit from prior plasma exchange with energy 
and mobility. Plasmapheresis was requested. However, based on the limited support found in currently 
available literature on plasmapheresis to treat multiple sclerosis, and the fact that the patient is not in a flare, 
there does not appear to be sufficient support made for this request. Therefore, the plasmapheresis will be 
considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve plasmapheresis for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychotherapy provided on December 3, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Psychotherapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Psychotherapy provided on December 3, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 services (70450) provided on January 21, 2022.