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

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the requested epidural steroid 
injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injections. 
 
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 epidural steroid injections. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injections. Our 
physician reviewer found in this case, there is no documentation of failure of non-invasive treatment including, 
physical therapy, exercise, spinal manipulation therapy, or oral NSAIDs. The review has determined that the 
requested lumbar epidural steroid injection 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a home ventilator is covered for the indications 
established in the applicable LCD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found 
that the record indicates that the enrollee has chronic respiratory failure from obstructive sleep apnea. 
Notwithstanding the fact that this is not an enumerated condition for which coverage is available. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc allograft procedure at lumbar level L1-2. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to show 
safety and efficacy. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested VIA disc allograft procedure at 
L1-2, in this case, 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc allograft procedure at lumbar level L1-2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stretch therapy service provided on January 5, 2022. 
 
You asked the Plan to pay for the stretch therapy service. You say that you purchased this plan due to the 
reimbursement plan, you have followed the protocols to be reimbursed, and have been denied. The Plan denied 
your request. The Plan says the stretch therapy service is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for membership in a qualified health club or fitness facility. 
 
The Plans rules for coverage of gym benefits have not been met because stretch therapy services do not fall 
under the allowance coverage. Therefore, we decided that the Plan does not have to pay for the stretch therapy 
service provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on January 5, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing 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 the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) and scanning 
computerized ophthalmic diagnostic imaging (92134) provided on March 24, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the outpatient office visit and diagnostic imaging. You say that you requested a 
referral from the enrollee's primary care physician's office, but one was not provided. You also say that you 
would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says there is not a valid referral or authorization on 
file.  
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 outpatient office visit (99204) and scanning 
computerized ophthalmic diagnostic imaging (92134) provided on March 24, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 2, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test which was medically 
necessary. The Plan denied your request. The Plan says this test was not billed in accordance with Medicare 
rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81442, 81411, 81439, 81410, 81413, 81414, 
81161, 81286 and 81256 billed for date of service October 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please find medical records supporting all 
billed charges. The Plan denied your request. The Plan says these are unbundled services and the services are 
not covered by Medicare. 
 
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 codes 81161, 81286 and 81256 are column II codes to column I code 
81442. This claim has not been billed with an appropriate modifier to bypass the edit. We have also confirmed 
that codes 81413 and 81414 are column II code to column I code 81439 with a modifier indicator of 0. The 
column II code is therefore not payable. For codes 81442, 81411, 814396 and 81410 Medicare denies coverage 
for all cardiovascular genetic risk assessment panels. Medicare only covers a lipid panel consisting of a total 
cholesterol, HDL cholesterol, and triglyceride once every 5 years as cardiovascular screening. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 81442, 81411, 81439, 81410, 81413, 81414, 81161, 81286 and 81256 billed for date 
of service October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided from 
April 22, 2022, to May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. You 
also say you were unaware that an authorization was required. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 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 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 hospital outpatient clinic visit (G0463) provided from April 
22, 2022, to May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 2, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on July 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 29, 2022, 
through February 18, 2022. 
 
You asked the Plan to pay for the home health services. You say that you sought information from the Plan 
regarding how to submit the NOA for this case and were not given clear instructions. You decided to submit an NOA with an admission date of January 1, 2022, and feel that payment for the final claim should be made. The 
Plan denied your request. The Plan says no NOA was submitted for this home health period. 
 
The Plan must follow Medicare rules. Medicare rules say that beginning on January 1, 2022, an NOA is used 
rather than RAPs for home health services. The instructions for submitting the NOA for ongoing home health 
care is explained in the Medicare rules section. 
 
We looked at the file and Medicare rules. Since this enrollee began with the HHA in 2021, an NOA with an 
admission date of the first day of the 30-day episode of care would be required. This admission date would be 
used with all subsequent claims. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from January 29, 2022, through February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (64490, 64491, J3301, Q9967) provided on 
December 15, 2021. 
 
You asked the Plan to pay for injections. You say that this is supported in the records. The Plan denied your 
request. The Plan says the submitted records are for an incorrect date of service. 
 
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 injections (64490, 64491, J3301, 
Q9967) provided on December 15, 2021, have been met. No medical records for the billed date of service have 
been submitted. Without this information, it cannot be verified that these services were performed. Therefore, 
we decided that the Plan does not have to pay for injections (64490, 64491, J3301, Q9967) provided on 
December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99239) provided on June 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 the services (99239) provided on June 21, 
2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vabysmo (J3590) and an intravitreal injection (67028). 
 
You asked the Plan to pre-approve Vabysmo and the intravitreal injection. You say that Vabysmo give the 
enrollee the best chance at recovering their vision, and requiring the least amount of treatments going forward. 
The Plan denied your request. The Plan says that Vabysmo is not first line treatment or standard of care for this 
case. The Plan also says there are several vascular endothelial growth factor inhibitors available on the market, 
and there is no documentation that Vabysmo is the only one that can be used. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Vabysmo and the intravitreal injection. 
Our reviewer says that Vabysmo is reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of neovascular (wet) age-related macular degeneration. Our 
reviewer found that the Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. Our physician reviewer also found that the elements of the coverage criteria are satisfied, 
and the requested service is 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 Vabysmo and the intravitreal injection have been met. Therefore, we decided 
that the Plan has to pre-approve Vabysmo (J3590) and an intravitreal injection (67028).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that you recommend the enrollee get Prolia injections twice 
per year to limit the progression of their osteoporosis. The Plan denied your request. The Plan says the criteria 
for coverage has not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Prolia. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate sufficient medical rationale that the enrollee has a contraindication to, or would have an adverse 
effect from the Plan's preferred step one alternative. Our reviewer also found that the elements of the coverage 
criteria are not satisfied, and 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You submitted medical records for review. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services provided on August 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, this is not an appropriate 
code for home therapy services, there is a more appropriate code to bill for the services provided. 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 the home therapy services provided on August 30, 2021.