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

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 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 Gel-one. Our reviewer says that Gel-
one is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our 
reviewer found that the record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the 
elements of the coverage criteria 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 Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on July 13, 2021. 
 
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your 
request. The Plan says it is the providers responsibility to bill the primary health plan or any liability insurance 
before submitting the claim to the enrollees plan. The Plan sates the enrollee has a primary health plan. 
 
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 needs the 
primary carriers Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the 
office services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the office services provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 8, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the doctor was only in the 
room with you for two minutes and told you to go elsewhere. You also say that neither you nor your insurance 
company should be responsible for the copayment. 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 $30 
copayment for a specialist office visit.  
 
 The record shows you had a specialist office visit on February 8, 2021. You have been asked to pay a $30 
copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, 
Including Doctors Office Visits 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 a 
specialist office visit provided on February 8, 2021.  
 
Your complaint about the amount of time the doctor spent with you is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure device and related 
equipment provided from April 13, 2021, through April 27, 2021, by a provider not certified with Medicare. 
 
You asked the Plan to pay for the medical equipment. You say that you needed this equipment immediately. 
The Plan denied your request. The Plan says this provider is not certified with Medicare and not eligible to 
receive payment from Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
device and related equipment provided from April 13, 2021, through April 27, 2021, by a provider not certified 
with Medicare.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next-generation sequencing (NGS) genetic testing. 
 
You asked the Plan to pre-approve NGS genetic testing. You say that the requested genetic testing is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
genetic 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 NGS genetic testing. Our reviewer says 
that the enrollee does not meet criteria for the requested genetic testing. Our physician reviewer found the 
enrollee has lung cancer (malignant neoplasm). She was previously approved a liquid panel for the cancer 
testing by Circulogene. Her cancer is stage 2 adenocarcinoma of the right lung. Member had lung surgery in 
February 2022. 
 
Per the reviewed documentation, the records received do not indicate the member has had a new cancer or that 
she has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not 
originate from the same primary cancer. The member's request does not show she had a new cancer or medical 
reasons she needed to repeat a solid tumor panel in addition to previous solid panel and liquid biopsy panel. 
The review has determined that the enrollee does not meet the above LCD and NCD criteria for the requested 
genetic testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NGS genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Next-generation sequencing (NGS) genetic testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you need to get to 
your provider's office. The Plan denied your request. The Plan says your benefit only allows 12 one-way trips 
with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 57.5 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from April 6, 2020, to 
April 9, 2020, as billed with DRG 219. 
 
You asked the Plan to pay for inpatient services billed with DRG 219. You say that these services were billed 
correctly, and the enrollee's diagnosis is supported in the medical record. The Plan denied your request. The Plan says DRG 219 is not supported as the secondary diagnosis of metabolic encephalopathy (G93.41) is not 
supported. The Plan argues that DRG 220 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 219 requires a secondary diagnosis of metabolic 
encephalopathy (G93.41). 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient services billed with DRG 219. Our 
reviewer says that the secondary diagnosis of metabolic encephalopathy is not supported in the medical record. 
Our physician reviewer found that the enrollee presented to the emergency room with complaints of abdominal 
pain. Upon exam, the enrollee was found to have an acute abdominal aortic dissection and was taken to the 
operating room. The appeal letter mentions that the enrollee required a sitter for post-op confusion and 
assistance with feeding. While this is noted, the enrollee was reported to have inability to use his upper 
extremities post-op and required assistance. Mention of post-op confusion is noted on the rehab note; however, 
supporting documentation was not found. Per the rehab note, The patient understands and is agreeable with 
the above plans. Documentation of encephalopathy cause, work-up, or treatment was not present in the record 
provided nor diagnosed on the discharge summary. Progress notes including, doing well, alert, 
cooperative, and alert and oriented, are included on progress and consult notes dated April 7, 2020, and 
April 8, 2020. The review has determined that the medical records did not support the billing of secondary 
diagnosis metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services billed with DRG 219 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from April 6, 2020, to April 
9, 2020, as billed with DRG 219.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services provided. We decided that the Plan does not have to pay 
for procedure code 85027 provided on July 29, 2021.  
 
You asked the Plan to pay for the services provided. You say that a signed order was received for the lab 
testing. The Plan says that an appropriate modifier was not billed. 
 
We decided that the Plan has to pay for procedure codes 80053 and 85025.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The case file includes a remittance which shows that the codes were denied. 
However, the case file does not clearly show why the codes were originally denied. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure codes 80053 and 85025 provided on July 
29, 2021.  
 
We also decided that the Plan does not have to pay for procedure code 85027. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The file shows that CPT code 85027 was billed with code 85025. We find that code 85027 may be eligible for 
payment when billed with this code pair. The claim information does not show that CPT code 85027 was billed 
with a modifier suitable for payment. Therefore, we decided that the Plan does not have to pay for procedure 
code 85027 provided on July 29, 2021. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortography (75625) provided on June 25, 
2021. 
 
You asked the Plan to pay for the abdominal aortography. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the the abdominal aortography. Our reviewer says that CPT 
code 75625 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not include enough documentation to confirm an abdominal aortography was performed.  
Abdominal aortogram describes imaging of the abdominal aorta, which is the segment of the aorta from the 
level of the renal arteries to the aortic bifurcation.  These are the landmarks which would be described to code 
for an abdominal aortogram. In this case, an abdominal aortogram cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the the abdominal aortography have not been met. Therefore, we decided that 
the Plan does not have to pay for the abdominal aortography (75625) provided on June 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips exceeding 50 miles of 
driving distance. 
 
You asked the Plan to pre-approve the routine transportation trips exceeding 50 miles of driving distance. You 
say that you have a device on your heart that helps keep it beating. You say that the device has airbags and 
sends a shock if your heart rate is too low. You say that the doctor you are requesting transportation to is the 
only one who can treat your medical condition. The Plan denied your request. The Plan says the benefit for 
transportation only allows coverage for trips that are 50 miles or less. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. The records show that you are requesting 
transportation to a location that is more than 50 miles from your home. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation trips exceeding 50 miles of driving distance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame/table system 
 
You asked the Plan to pre-approve a standing frame/table system. You say that the standing frame is needed so 
you can stand and have exams that require you to be standing. You say that the requested device is a necessity 
because your husband does not have the strength anymore to be in charge and help you. The Plan denied your 
request. The Plan says the item being requested is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a standing frame/table system
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve these services. You say that this procedure is the only way for you to walk 
again. The Plan denied your request. The Plan says that this service 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 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested spinal cord stimulator. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer 
found the enrollee has chronic low back pain whose etiology is not clear. The enrollee's thoracic spine 
Computed Tomography (CT) scan revealed mild-to-moderate degenerative changes and only mild 
neuroforaminal narrowing. On March 23, 2022, the member reported chronic low back pain with bilateral 
lower extremity radiation, worse on the right. Hydrocodone/APAP was prescribed. Prior treatment includes 
epidural steroid injections and radiofrequency ablations. There were no neurological deficits noted on physical 
examination. The enrollee has not had any spine surgery. The enrollee does NOT have an evidence-based 
indication for a spinal cord stimulator trial. The request 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the application of an upper extremity cast 
provided from May 27, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayments for the application of an upper extremity cast. 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 $250 
copayment for in and out of network outpatient surgery at an outpatient hospital facility.  
 
The application of an upper extremity cast is considered a surgical procedure. The record shows you had a cast 
application on May 27, 2021, June 3, 2021, June 17, 2021, and June 18, 2021.  You have been asked to pay a total of $1,000, which is a $250 copayment for each cast application. The 
application of an upper extremity cast falls within the Outpatient Surgery, Including Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the application of an upper extremity cast provided from May 27, 2021, to June 
18, 2021.  
 
Your complaint about your payments not showing up on the providers billing is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi 100MG/ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Simponi is on the self-administered drug list and is excluded from coverage under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Simponi 100MG/ML injection.