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

 
We decided that the Plan does not have to pay for the laboratory services coded as 84153, 84154, 84207 and 
84255 provided September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you requested additional diagnosis from the 
referring physician office which were received very late. Upon receiving the correct diagnosis, you submitted 
your claim for reconsideration. The Plan denied your request. The Plan says this claim was submitted after the 
timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services 84153, 84154, 84207 and 84255 provided September 
21, 2021. was not filed until November 14, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded as 84153, 84154, 84207 and 84255 provided September 21, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 26, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology services. You say that the service should be covered. 
The Plan denied your request. The Plan says there are in-network providers that can perform this service. 
 
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 
the ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect test (0012M) provided June 22, 2022. 
 
You asked the Plan to pay for Cxbladder Detect test. You say that you believe that the evidence supporting the 
use of Cxbladder detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the Cxbladder test is considered experimental/ investigational and not approved. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of Cxbladder Detect test have not been met. Therefore, we decided that the Plan does not have to pay 
for Cxbladder Detect test (0012M) provided June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the phlebectomies (37765). 
 
You asked the Plan to pre-approve the phlebectomies. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy.  
 
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 phlebectomies. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found while there is satisfactory 
documentation that the varicose tributaries are greater than 4mm in diameter (duplex worksheet), there remains 
untreated saphenous reflux bilaterally. The health plan does not provide for simultaneous saphenous and 
tributary treatment. 
 
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 phlebectomies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the phlebectomies (37765).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that you feel this drug would be in the enrollee's best 
interest and medically necessary. The Plan denied your request. The Plan says this request does not meet the 
Plan's Part B step therapy criteria for Entyvio. 
 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 Entyvio. Our reviewer says that the 
criteria for coverage of this drug has not been met. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drugs. Our physician reviewer also found that there is no indication 
that the Plan's 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 30, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim 
was received past the Medicare allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until October 24, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like this 
authorized because you believe it is medically necessary and you need it before surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 4, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer procedure 
(22867, 22868, 22869 and 22870). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you highly recommend this minimally 
invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal 
fusion procedure. The Plan denied your request. The Plan says the use of Vertiflex Superion Interspinous 
Spacer is considered experimental and investigational. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Vertiflex Superion Interspinous Spacer procedure (22867, 22868, 22869 and 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive pharmacogenetics panel 0031U, 81291, 
81328, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81355 and 81404 provided July 19, 2022 
 
You asked the Plan to pay for the laboratory service. You say that please find the attached documents and 
review and reconsider the claim for payment. The Plan denied your request. The Plan says the clinical value 
and effectiveness of comprehensive pharmacogenetic testing have not been demonstrated in the peer-reviewed 
literature. 
 
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. 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 comprehensive pharmacogenetics panel 0031U, 81291, 81328, 0032U, 81225, 81226, 81227, 81230, 
81231, 81240, 81241, 81355 and 81404 provided July 19, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery (45385) provided on February 25, 2022. 
 
You asked the Plan to pay for outpatient surgery (45385). You say that the service was medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient surgery 
(45385) provided on February 25, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
require close supervision by a physician and there is no evidence the enrollee can participate in intensive 
therapy, medically necessary care may be provided safely in a different level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography, head or brain (code 70450) 
provided on September 19, 2022. 
 
You asked the Plan to pay for the computed tomography, head or brain (code 70450). The Plan denied your 
request. The Plan says an explanation of benefits (EOB) from the members primary insurance carrier is needed 
before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the EOB from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
computed tomography, head or brain (code 70450) until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for a computed tomography, head or brain 
(code 70450) provided on September 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plan's network) will not be covered. 
 
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 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve this service. You say that continued inpatient psychiatric hospital care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that continued inpatient 
psychiatric hospital care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the enrollee was admitted for 
an acute inpatient psychiatric hospitalization on December 8, 2022 with Schizoaffective Disorder Bipolar Type, 
Traumatic Brain Injury (TBI), and Intellectual Disabilities. Based upon the review of the records provided, it 
was not expected that this enrollee would improve in a reasonable period of time beyond the date in question as 
he was not showing any dangerousness to self or others, auditory or visual hallucinations, and was without 
aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the date in question as he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations or abnormal behaviors. The health plans denial of continued inpatient psychiatric services 
appears appropriate. This enrollee does not require inpatient mental health treatment beyond the date in 
question as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It does not appear that active treatment was taking place beyond the date in question. It does not 
appear that the service for the date in question is reasonably expected or medically necessary to improve the 
enrollees condition or is for the purpose of a diagnosis. Based upon the review of the records provided, this 
enrollee does not meet the criteria for continued acute inpatient mental health treatment beyond the date in 
question of February 8, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy (31624) provided on June 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the bronchoscopy. You say that you are expecting a reimbursement of $1,597.02. 
The Plan denied your request. The Plan says the enrollee's plan excludes coverage for this OON service. 
 
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 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 bronchoscopy (31624) provided on June 15, 
2022, by an out-of-network (OON) provider.