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

 
We decided that the Plan does not have to pre-approve injections of diagnostic or therapeutic agent (64493, 
64494). 
 
You asked the Plan to pre-approve injections of diagnostic or therapeutic agent. You say that the requested 
services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules 
for the requested services have not been met. 
 
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 injections of diagnostic or therapeutic 
agent.  Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the documentation does not reveal that you have had two medically 
reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 
80% relief of primary pain and subsequent therapeutic facet joint procedures at the same anatomic site result in 
at least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 
50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to 
baseline measurement using the same scale. There is no documentation of why you are not a candidate for an 
RFA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections of diagnostic or therapeutic agent have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injections of diagnostic or therapeutic agent (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on August 
13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization, and the nursing home was responsible to obtain 
prior authorization for their patients, which should cover medical treatments by the provider. The Plan denied 
your request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained 
prior to the services being rendered. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided 
on August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test rendered at an 
outpatient hospital facility on April 20, 2021. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $225 
copayment for Outpatient hospital services.  
 
 You have been asked to pay a $225 copayment for a comprehensive hearing test. Comprehensive hearing tests 
fall within the Outpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a comprehensive hearing test rendered at an outpatient hospital facility on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq and Heparin Sodium for the enrollee. 
 
You asked the Plan to pre-approve Tecentriq and Heparin Sodium. You say that these drugs are medically 
necessary. The Plan denied your request. The Plan says that the use of these drugs are not reasonable and 
necessary. 
 
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 Tecentriq and Heparin Sodium. Our 
reviewer says that Tecentriq and Heparin Sodium are not medically reasonable and necessary.  
 The record indicates that the enrollee has a diagnosis of advanced, newly progressive adenocarcinoma, PDL-1 
zero, tumor marker burden high non-small cell lung cancer. The record indicates that the enrollee progressed 
after treatment with Keytruda and Opdivo. The Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of Tecentriq and Heparin Sodium. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq and Heparin Sodium have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Tecentriq and Heparin Sodium for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided 
August 30, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services provided were medically necessary and meet all applicable professionally recognized standards of 
healthcare. The Plan denied your request. The Plan says the services are not supported without the required 
documentation. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90832) provided August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 1, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 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. The claim shows that the services were billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone mass measurement provided on February 12, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this service is 
covered once every 2 years. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 77080 is dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine).  
 
We looked at the file and the rules. The test at issue was provided less than 2 years since the previous test was 
performed. There are no records to show that the enrollee required a test more frequently than every 2 years. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the bone mass measurement provided on 
February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing (CPT code(s): 81225, 
81226, 81227, 81230, 81240, 81241, 81291, and 81355) provided on August 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The enrollee had 
molecular pharmacogenetic testing on August 19, 2021.  The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the molecular pharmacogenetic testing (CPT code(s): 81225, 
81226, 81227, 81230, 81240, 81241, 81291, and 81355) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (CPT code G0439) provided on 
November 2, 2021. 
 You asked the Plan to pay for the annual wellness visit. You say that you had to change your primary care 
physician due to COVID-19. You state your new physician required a new annual wellness visit in order for 
you to be seen. The Plan denied your request. The Plan says the service is a covered benefit, but you have 
exceeded the limits set in the subscribers agreement. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Per your EOC, if youve had Part B for longer than 12 months, you can get an annual wellness visit to develop 
or update a personalized prevention plan based on your current health and risk factors. You dont have to wait a 
full year to get your Annual Wellness Visit, you can get it once every calendar year. For covered services that 
have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for 
that type of covered service. You received an annual wellness visit on July 23, 2021, and then received another 
annual wellness visit on November 2, 2021, with a different provider. Therefore, the claim denied correctly, 
and you are responsible for the full amount of the service for $160.00. Therefore, we decided that the Plan does 
not have to pay for the annual wellness visit (CPT code G0439) provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ongoing inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the hospital services being received no longer require inpatient care 
anymore. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found inpatient acute hospital care was not medically necessary from 1/26/2022 until 
discharge on 2/2/2022. You were admitted on 1/14/22 with abdominal pain and a small bowel obstruction. Care 
was complicated by severe obesity, acute respiratory failure, and a history of thromboembolic disease. Surgery 
was performed on 1/17/22. By 1/25/22, you were tolerating oral intake, were hemodynamically stable, 
oxygenating adequately on 2 LPM, and were deemed ready for discharge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for ongoing inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
chronic obstructive pulmonary disease (COPD) with chronic respiratory failure. The Plan denied your request. 
The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support 
(AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  You have severe COPD. You were recently 
hospitalized with aspiration pneumonia, and an arterial blood gas (ABG) showed mild carbon dioxide (CO2) 
retention. There is no ABG done while you are stable as an outpatient. BiPAP has not been tried. Medicare 
does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that medical records do not support these 
services. 
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you do not have dangerousness to self or 
others, auditory or visual hallucinations, delusions and are not showing any aggressive behavioral issues. It 
does 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 as you do not have dangerousness to self or others, perceptual 
disturbance including auditory or visual hallucinations. Our physician reviewer found that your condition does 
not meet criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to require additional short-term acute care services to further stabilize 
until more appropriate for a lower level of care. Care can be safely administered at the current facility until this 
time. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer may be considered when treatment has completed and you are more stable. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below his 
reported baseline. The documentation does not yet establish that the enrollee has reached a new, lower, level of 
function. Daily skilled services are reasonably required to improve strength, improve endurance, establish a 
maintenance program and/or prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 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.