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

 
We decided that the Plan does not have to pay for lab services billed with codes 87641, 87581, 87486, 87653, 
87798 59, 87541, 87498, 87496, 87651 for date of service March 17, 2022.  
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says no valid order or requisition for these specific lab codes 
was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that there must be evidence of an order or requisition 
from the patient's treating physician for lab services. You did not provide any order or requisition evidencing 
the patient's physician's intent to order lab services represented by codes 87641, 87581, 87486, 87653, 87798 
59, 87541, 87498, 87496, 87651. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with codes 87641, 87581, 87486, 87653, 87798 59, 87541, 87498, 87496, 87651 for date of 
service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral myringotomy with tympanostomy tubes. 
 
You asked the Plan to pre-approve bilateral myringotomy with tympanostomy tubes. You say that this 
procedure is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The 
Plan says the criteria for the requested procedure have not been 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 bilateral myringotomy with 
tympanostomy tubes. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had 
impacted cerumen that caused hearing deficit. The record indicates that the enrollee has previously had 
tympanostomy tubes but does not indicate recent recurrent or current infection. The provided record is 
insufficient to establish the medical necessity of the requested procedure at this time. 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 bilateral myringotomy with tympanostomy tubes have not been met. Therefore, 
we decided that the Plan does not have to pre-approve bilateral myringotomy with tympanostomy tubes.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 30, 2022, to June 28, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that the claim and NOA have certain data elements that are 
required. 
 
Review of the file shows that a valid NOA with an admission date of January 30, 2022 was received on April 
22, 2022. The denied claim for dates of service May 30, 2022, through June 28, 2022 has an admission date of 
September 2, 2021. Since the first date of service for the plan year 2022 is January 30, 2022, this is the correct 
admission date to be entered on all subsequent final claims. As the claim has incorrect information, no payment 
can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home health 
services provided May 30, 2022, to June 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 14, 2022, to 
May 11, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 14, 2022. The NOA was not received by the Plan until January 19, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from April 14, 2022, to May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk without having breathing 
complications and need around the clock care. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Baroreflex stimulation implanted device (0266T). 
 
You asked the Plan to pre-approve a Baroreflex device. You say that the enrollee's heart failure is progressively 
worsening such that they qualify for the Barostim Neo device to improve symptoms, functional capacity and 
quality of life since they remain symptomatic despite being on maximal tolerated dose of medical therapy. The 
Plan denied your request. The Plan says studies by medical scientists do not show that the treatment is safe and 
works as well as other, more commonly used tests or treatments. The request for Baroreflex stimulation 
implanted is considered experimental, investigational, or unproven. Experimental, investigational, and non -
standard treatments are not covered as they are not proven to be safe and or 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 a Baroreflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Barostim Neo system is an electronic pulse generator implanted underneath the 
clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019 the FDA approved the system for use in patients with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study 
demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac 
levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the 
Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical 
management. 
 
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 Baroreflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Baroreflex stimulation implanted device (0266T).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the diagnostic breath testing performed on July 8, 2022, 
and July 12, 2022. 
 
You asked the Plan to hold you harmless for the breath testing. You say that you are upset that this test was not 
covered because you told the provider prior to completing it that you could not afford this if it was not covered. 
You state that the provider assured you it was covered by Medicare and that a Plan representative had relayed 
this information. You indicated that you did not receive a denial notice until after the weekend during which 
you did the test and had already sent the samples back to the provider. You feel that this should be covered as it 
was necessary to prescribe treatment which alleviated your symptoms. The Plan denied your request. The Plan 
says that this test is noncovered nationally due to a Medicare regulation. As such, the claim was correctly 
denied. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the breath testing by a contract provider. You claim that this provider assured you that 
the test was covered by Medicare, and you were told that the Plan said the same. The Plan did not investigate 
these allegations and request call logs or other information from the network provider. Though a Notice of 
Denial of Medical Coverage (NDMC) was issued dated June 22, 2022, you state that you did not receive this 
until after you completed the test. The Plan states that the denial was faxed to your provider on June 22. We 
find that since your provider wrongly indicated this test was Medicare-covered, you were given 
misinformation. We note that the provider would be expected to know which commonly prescribed tests are 
nationally noncovered by Medicare. Since the provider did not inform you verbally and confirm that you were 
aware that this test was denied coverage, we find that you reasonably believed the test was covered at the time 
you took it. As such, this test is considered approved by the Plan, which must ensure that the provider does not 
bill you for these services. Therefore, we decided that the Plan has to hold you harmless for the diagnostic 
breath testing performed on July 8, 2022, and July 12, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
6, 2022, to January 18, 2022. 
 
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 admission date is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 home health services provided to the enrollee from January 6, 2022, to January 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve quantitative calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that the enrollee would 
benefit from having a continuous glucose monitor to allow better management. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for a continuous glucose monitor. 
 
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 therapeutic continuous glucose monitor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose 
monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided from June 7, 2022, to 
June 27, 2022. 
 
You asked the Plan to pay for outpatient therapy services. You say that this is supported in the records. The 
Plan denied your request. The Plan says this was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when exceptions are in effect and the beneficiary 
qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy code subject to the 
cap limits. 
 
We looked at the file and Medicare rules. The record shows that the therapy cap was exceeded for this enrollee, 
but the services at issue were not billed with the KX modifier. Based on this information, we decided that 
Medicare rules for coverage of outpatient therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient therapy services provided from June 7, 2022, to June 27, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee 
from July 2, 2022 to July 31, 2022. 
 You asked the Plan to pay for SNF care. You say that you are appealing the denied payment with medical 
records. The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled 
services at a SNF level of care 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that on the day after the fall, the enrollee was independent with bed mobility, set up 
for transfer, and supervisory for ambulation. There were no daily skilled nursing or skilled therapy needs. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided to the enrollee from July 2, 2022 to July 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from intensive therapy. 
The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve the Coflex device. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the Coflex lumbar interspinous decompression device 
is unproven and not medically necessary due to insufficient evidence of efficacy. 
 
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 Coflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental. More research is needed to show safety and 
efficacy before coverage of this device cannot be approved. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex device.