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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection for low back. 
 
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
an epidural steroid injection of the low back does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found in this 
case, there is no documentation of the percentage of pain relief. The enrollee does not meet the coverage 
indications for the requested epidural. The review has determined that it is not medically necessary or 
reasonable for this enrollee to have the lumbar epidural steroid injection as requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection for low back.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nurse services. 
 
You asked the Plan to pre-approve private duty nurse services. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 private duty nurse services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, you are 
medically stable and require custodial care. The requested 50 visits of a private duty nurse are 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 private duty nurse services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve private duty nurse services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing provided on November 15, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include testing for the FANCC gene 
are non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the panel rendered included testing for 
the FANCC gene. This means the entire panel is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing provided on November 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stress testing. 
 
You asked the Plan to pre-approve stress testing. You say that the requested stress testing is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
stress testing. 
 
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 stress testing. Our reviewer says that 
the enrollee does not meet criteria for the requested stress testing. Our physician reviewer found the enrollee 
had a negative stress test in March 2021. The enrollee does not have symptoms. There is no evidence provided 
that would support the need for radionuclide stress testing at this time. In summary, there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing 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 stress testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stress testing.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services provided on August 31, 2021. 
 
You asked the Plan to pay for the hospital discharge services. You say that the hospital discharge services were 
necessary.  The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge services provided on August 31, 2021.
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 the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with dyspnea in the setting of pneumonia.  The record indicates that although the enrollee is 
improving, he requires ongoing acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on  
May 17, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. The Plan denied your request. The Plan 
says your cost share applied correctly to the claim. 
 
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 $125 
copayment for Ambulance Services.  
 
You have been asked to pay $125 copayment for ambulance services. Ambulance services falls within the 
Ambulance 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 ambulance services 
provided on May 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
May 17, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. The Plan denied your request. The 
Plan says your cost share applied correctly to the claim. 
 
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 $110 for 
Emergency Care.  
 
You have been asked to pay $110 for emergency room services. The emergency room services 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 copayment for emergency room 
services provided on May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on June 10, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and 
necessary. Our physician reviewer found that the documentation does not support that other means of transport 
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this 
enrollee. The records cite "confusion" as the reason the enrollee could not be transported by other means but 
describe him as alert and oriented and able to walk to the stretcher with assistance. He could have safely been 
transported by another type of vehicle. The documentation does not support that the enrollee needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can 
provide for safe transport. The enrollee was transferred from a living facility for an elective outpatient 
procedure with urology. There is no documented medical need for BLS or ALS services during transport. The documentation does not support that the ambulance transport was medically reasonable and necessary 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 ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer purchased on December 30, 2021. 
 
You asked the Plan to pay for these services. You say that you need the equipment for your medical conditions. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that enrollees may purchase durable medical equipment 
(DME) after renting for 10 months. The rules say that Medicare pays for services only when they are furnished 
by a provider or supplier enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. The file shows that you purchased the nebulizer and did not rent from 
a Medicare-certified provider. Therefore, we decided that the Plan does not have to pay for the nebulizer 
purchased on December 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME (CPT code(s): A7030, A7035, A7038, A7037, 
A7039, and A7046) provided on February 12, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code(s): A7030, A7035, A7038, A7037, A7039, and A7046, remain not supported. The documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of 
delivery for the billed date of service. Therefore, we decided that the Plan does not have to pay for the DME 
(CPT code(s): A7030, A7035, A7038, A7037, A7039, and A7046) provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided December 2, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne Hme was ordered by the 
treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says targeted genomic sequence analysis panel is non-covered 
by Medicare. 
 
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. Genetic testing procedures submitted with code 81455 are unlikely 
to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the targeted genomic sequence analysis panel (81455) provided December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82747, 83540, 6036, 36415, 80048, 
80061, 84443, 83036, 80076) and specimen collection, travel allowance (P9604) provided on January 13, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
 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 the laboratory services (82747, 83540, 6036, 
36415, 80048, 80061, 84443, 83036, 80076) and specimen collection, travel allowance (P9604) provided on 
January 13, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo (Q5120). 
 
You asked the Plan to pre-approve Ziextenzo. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
  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 Ziextenzo. Our reviewer says that 
Ziextenzo is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
two of the preferred step therapy drugs, Neulasta (Pegfilgrastim), Fulphila (Pegfilgrastim-jmdb), and Udenyca 
(Pegfilgrastim-cbqv) before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. Our reviewer also found that 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo (Q5120).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, 
including physical and occupational therapy, the documentation does not reveal that the enrollee requires this 
therapy on an intensive IRF level. Therapy notes indicate the enrollee is limited by pain and weight bearing 
restrictions. He does not require therapy on an intensive level 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, 
including physical and occupational therapy, the documentation does not reveal that the enrollee requires this 
therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus gene panel (81210, 81235, 81245, 81272, 81275, 
81276, 81310, 81311, 81315) provided on May 19, 2021. 
 
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the submission of claims 
using individual gene CPT codes, when either 5-50 or more than 50 gene panels are ordered, is considered 
incorrect coding. 
 
We find that CPT codes 81210, 81235, 81245, 81272, 81275, 81276, 81310, 81311, and 81315 are not 
supported in the medical record. Specifically, these codes were used to report components of a panel, which is 
considered incorrect coding. Based on this information, we decided that Medicare rules for coverage of a 
Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus 
gene panel (81210, 81235, 81245, 81272, 81275, 81276, 81310, 81311, 81315) provided on May 19, 2021.