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

 
We decided that the Plan does not have to pay for code 81479 billed for date of service August 24, 2022. 
 
You asked the Plan to pay for code 81479. You say that this testing was medically necessary and was billed 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 81479 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 81479 billed for date of service 
August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services and drugs 
(A9270) you received on September 8, 2022. 
 
You asked the Plan to waive the services. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $290 
copayment for outpatient surgery services.  
 
Review of the file shows that you were provided outpatient surgery (19302) on September 8, 2022. You have 
been asked to pay a $290 copayment for the outpatient surgery services. This service falls within the outpatient 
surgery 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. 
 
The rules also 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 waive the copayment for the outpatient surgery services and drugs 
(A9270) you received on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for follow-up hospital inpatient care per day, typically 35 
minutes (99233), provided on October 17, 2021, through October 19, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says procedure code 99233 remains not supported. 
 
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 inpatient care have been met. 
missing medical records. Therefore, we decided that the Plan does not have to pay for follow-up hospital 
inpatient care per day, typically 35 minutes (99233), provided on October 17, 2021, through October 19, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance angiography (MRA) of head without contrast 
material (70544), provided on August 10, 2022. 
 
You asked the Plan to pay for an MRA. You say that this claim denied in error. The Plan denied your request. 
The Plan says that there's an edit with procedure code 70544. 
 
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. The plan did not substantiate their denial, as they did not show what code that 
CPT 70544 is in an edit with, and they didnt provide a claim. Therefore, we decided that the Plan has to pay 
for a magnetic resonance angiography (MRA) of head without contrast material (70544), provided on August 
10, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's diagnoses qualify for an IRF 
admission, an IRF admission is medically necessary, and you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 94640 billed for date of service October 20, 2022. 
 
You asked the Plan to pay for code 94640. You say that this service was provided emergently and should be 
covered. The Plan denied your request. The Plan says this service is not separately payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 
 Records show that code 94640 has a status indicator of Q1, meaning that it is an STV-packaged service.  This 
means that if it is billed on the same claim with a code that has a S, T, or V status indicator, there can be no 
separate payment made.  In this case, code 94640 was billed on the same claim as code 99284.  Code 99284 
(and its associated outpatient hospital revenue code of 450), has a status indicator of V.  This means that code 
94640 cannot be separately paid.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 94640 have not been met. Therefore, we decided that the Plan does not have to pay for code 
94640 billed for date of service October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower partial dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures did not fit correctly. 
You do not have dentures at this time. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 14, 2022. 
Therefore, we decided that the Plan does not have to pre-approve lower partial dentures (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the requested Freestyle Libre 2 
sensor is medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 sensor.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown (D6740 x 2) and pontic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that replacing the current bridge makes the 
most sense. The Plan denied your request. The Plan says that the documentation provided does not demonstrate 
any specific need or condition that precludes the use of a removable prosthesis. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the request is medically reasonable and necessary. Our physician reviewer found that a review of the 
documentation indicates that the current bridge is defective and needs replacing. Since the treatment would 
involve placing new crowns on teeth numbers 19 and 21, it is medically reasonable to replace missing tooth 
number 20 with a pontic rather than a removable appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve retainer crown (D6740 x 2) and pontic (D6245).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system for your power 
wheelchair (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this item is vital to your 
independent living. The Plan denied your request. The Plan says this item is not covered because it does not 
serve a medical purpose. 
 
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 power seat elevation system for your power wheelchair 
(E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of iron deficiency anemia, unspecified. The documentation does not support 
that the enrollee has tried and failed Ferrlecit (Sodium Ferric Gluconate Complex), INFeD (iron dextran), or 
Venofer (iron sucrose). The documentation does not support that Ferrlecit (Sodium Ferric Gluconate Complex), 
INFeD (iron dextran), or Venofer (iron sucrose) would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 Actemra. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of rheumatoid arthritis previously treated with methotrexate, 
Humira, Orencia and ibuprofen. Actemra at a dose of 8mg/kg as the initial dose for rheumatoid arthritis with a 
history of inadequate response to disease modifying antirheumatic therapy does not meet all Medicare criteria 
for medically reasonable and necessary for the enrollee. The Medicare-approved major drug compendia do not 
support the use of Actemra at a dose of 8mg/kg as the initial dose for rheumatoid arthritis with a history of 
inadequate response to disease modifying antirheumatic therapy. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Select MDX testing provided on October 14, 2022. 
 
You asked the Plan to pay for the Select MDX testing. You say that the test was ordered by the treating 
physician, who is tasked with performing the professional determination of diagnosis and prescription of a 
treatment approach that is medically necessary. The Plan denied your request. The Plan says that this test does 
not meet requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that Select MDX testing is coverable when medically 
necessary to inform the decision to perform an initial biopsy (prebiopsy), and the test will be performed to 
further refine risk when a biopsy has been performed but does not clearly indicate malignancy on 
histopathologic examination (post-biopsy). Such a test can potentially obviate the need for a repeat 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 Select MDX testing. Our reviewer says 
that this test was medically necessary in accordance with Medicare rules. Our physician reviewer found The 
records show that the enrollee has a digital rectal exam suspicious for cancer and a biopsy is being considered 
based upon the Select MDX test results.  
 
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 Select MDX testing have been met. Therefore, we decided that the Plan has 
to pay for the Select MDX testing provided on October 14, 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: Other
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on September 18, 2022, through 
September 23, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that the claim was processed 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 Plan has failed to forward any evidence supporting their 
rationale for denial. There is no indication of what specific services were billed or why they were denied. Of 
note, the record indicates that the Plan upheld their denial based on untimely filing of the appeal. This is not an 
appropriate rationale for denial. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that 
the Plan has to pay for inpatient hospital services provided on September 18, 2022, through September 23, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom CGM. 
 
You asked the Plan to pre-approve a CGM. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom CGM.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monthly COVID-19 test subscription-type service 
provided on November 2, 2022. 
 
You asked the Plan to pay for the monthly COVID-19 test subscription. You say that you are upset that you 
have been sent 15 different denials by the Plan. The Plan denied your request. The Plan says there is no record 
that this testing was being done for any reason other than a screening situation. The Plan also says that you 
were not in need of special care that was not available in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic X-Ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary and tests not 
ordered by the physician who is treating the beneficiary are not reasonable and necessary. 
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the record shows that these tests were ordered by 
someone who you were not being treated by, and the order would not be valid. Based on this information, we 
decided that Medicare rules for coverage of the monthly COVID-19 test subscription have not been met. 
Therefore, we decided that the Plan does not have to pay for the monthly COVID-19 test subscription-type 
service provided on November 2, 2022.