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

 
We decided that the Plan does not have to pre-approve zaleplon capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that it would be in the enrollee's best 
interests to continue this medication. The Plan denied your request. The Plan says the denial of authorization 
for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer 
the enrollee's Medicare Part D prescription drug benefits. 
 
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 zaleplon capsules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided by a 
participating provider on January 4, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you would have never had 
these services done if you knew that they were not covered. The Plan denied your request. The Plan says the 
rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
  
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided by a participating provider on January 4, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy services provided on September 1 to September 20, 
2021. 
 
You asked the Plan to pay for physical therapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been 
met because the services at issue were home health services not billed with codes applicable to home health 
services. 
 
The Plan must follow Medicare rules. The rules say that therapy services are payable under the Physician Fee 
Schedule when furnished by a provider as specified in the Medicare rules section. 
 
We looked at the file and Medicare rules. The services at issue were not rendered or billed under a home health 
plan of care. The services were billed with the appropriate codes. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have been met. Therefore, we decided that the Plan 
has to pay for physical therapy services provided on September 1 to September 20, 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 cardiac risk assessment genetic screening testing provided to 
the enrollee on July 28, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found that this genetic testing would not reasonably change the treatment plan or 
outcome for this patient as they already have significant risk factors that would justify more aggressive 
treatment for diabetes and cardiovascular disease. Therefore, this request for genetic cardiovascular 
screening/risk assessment panel testing will be considered 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx for Prostate Cancer Epigenetic Molecular 
Assay (CPT code 81551) provided on November 19, 2021. You asked the Plan to pay for the laboratory services. You say that this service should be covered based on 
Medicare guidelines. The Plan denied your request. The Plan says Medicare guidelines require previous 
negative biopsy done in last twenty-four (24) months and persistent risk factors for ConfirmMDx to be 
approved. The Plan states per NCCN guidelines, ConfirmMDx is not recommended to be done at the same time 
as the biopsy. 
 
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 the laboratory services. Our physician 
reviewer found the review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx for Prostate Cancer Epigenetic Molecular Assay (CPT code 81551) 
provided on November 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided to the enrollee from 
September 7, 2021, to September 9, 2021. 
 
You asked the Plan to pay for the drugs. You say that additional payment should be made. The Plan denied 
your request. The Plan says these are covered under Part D. 
 
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 pay for self-administered drugs provided 
to the enrollee from September 7, 2021, to September 9, 2021.  
 
Benefits for the drugs may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the programming device evaluation rendered on January 14, 
2021. 
 
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 services are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93280 
is a column II code to column I code 93724. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the programming device evaluation rendered on January 14, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 1, 
2021. 
 
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 date of service does not match. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 11042 and 10060 is not supported in the medical record. Specifically, the operative 
report shows a date of service of September 2, 2021. 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 
surgical services provided to the enrollee on September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography provided on December 9, 2021. 
 
You asked the Plan to pay for screening mammography. You say that you missed your 2020 routine 
mammogram, and you received two routine mammograms in 2021, one in April and one in December. You say 
that both should be covered. The Plan denied your request. The Plan says you have already received the 
maximum amount of coverage allowed for this type of service. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the Plans rules. The file shows that you received the maximum benefit coverage. 
Therefore, we decided that the Plan does not have to pay for screening mammography provided on  
December 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on July 11, 2021. 
 
You asked the Plan to pay for the CT scan. 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 CT scan provided on July 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
September 15, 2021. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the continuous glucose monitor (CGM) supplies rendered on 
September 15, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Pemetrexed for the enrollee. 
 
You asked the Plan to pre-approve Pemetrexed. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that use of this drug, Pemetrexed, is not FDA approved for this type of cancer, and 
there is lack of support for its use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pemetrexed. Our reviewer says that 
Pemetrexed is medically reasonable and necessary. Pemetrexed is not FDA-approved for the enrollees 
diagnosis. The use of Pemetrexed is supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Due to the rarity of cancer there is a need to rely on available 
literature which is case reports. Patient will be part of a clinical trial with pembrolizumab that requires 
insurance coverage of Pemetrexed. Pemetrexed is safe and effective and otherwise reasonable and necessary 
for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of 
Pemetrexed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pemetrexed have been met. Therefore, we decided that the Plan has to pre-
approve Pemetrexed for the enrollee.  
 
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 GeneSight Psychotropic testing (CPT code 81479) 
provided on November 22, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that the claim should be paid. The 
Plan denied your request. The Plan says the services were not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the GeneSight Psychotropic testing 
have been met. There is no clinical information to corroborate the Local Coverage Determination (LCD). 
Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing (CPT code 
81479) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on September 2, 2021. 
 
You asked the Plan to pay for the critical care services. You say that this was billed correctly. The Plan denied 
your request. The Plan says no time spent was documented as required. 
 
The Plan must follow Medicare rules. Medicare rules say that records must document time spent providing 
critical care services. 
 
We looked at the file and Medicare rules. The time spent providing care was not documented as required for 
payment of critical care services. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services provided on September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy (OT) services provided on July 2, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OT services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained before the services were rendered. The 
Plan also says that the services were not part of an emergency 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 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 occupational 
therapy (OT) services provided on July 2, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for the at-home coronavirus test provided on January 22, 2022. 
 
You asked the Plan to reimburse you for the at-home test. You say that information you have found indicates 
that private insurances should be covering the at home Covid19 test in full. You say that this is the case for 
tests purchased after January 15, 2022. The Plan denied your request. The Plan says that the claim denied 
correctly. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file indicates that the Plan is using undated/out of date rule to 
deny this claim. The record shows that the current guidance indicates that plans will pay for at home tests 
purchased after January 15, 2022. Therefore, we decided that the Plan has to reimburse you for the at-home 
coronavirus test provided on January 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx test provided to the enrollee on 
March 29, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this type of testing will not affect the treatment and management of the enrollee's condition. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records do not indicate that coverage criteria as outlined in National Coverage Determination (NCD) 
for Next Generation Sequencing (NGS)(90.2) have not been met. Specifically, the records do not show that the 
enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne CDx test provided to the enrollee on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx test (0037U) provided November 18, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of this service meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of FoundationOne CDx test (0037U) 
provided November 18, 2021. have been met. Medical records was required to determine how the enrollee 
came to the servicing provider and to support medical necessity. The Plan made several attempts to obtain 
records from the provider without success. Therefore, we decided that the Plan does not have to pay for 
FoundationOne CDx test (0037U) provided November 18, 2021.