Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated 
(36475). 
 
You asked the Plan to pre-approve the procedure. You say that please find the attached authorization 
reconsideration request to have the authorization approved. The Plan denied your request. The Plan says 
request is not medically necessary because there is no documentation that conservative care has been tried and 
has failed. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is documentation that the enrollee is walking without difficulty. On physical examination 
there is documentation that she has no edema. The reflux noted in the great saphenous vein is minimal and 
focal. Ablation of this vein would ablate what, for the vast majority, is a normal vein. The duplex suggests that 
the patient is already status post ablation of bilateral calf great saphenous veins and a small saphenous vein as 
well. As noted by the health plan, there is no documentation of any effort at conservative treatment. There is 
also no documentation that the enrollee is experiencing life limiting symptoms as result of varicose veins. The 
documentation does not meet coverage criteria and does not support the medical necessity of the treatment in 
question. 
 
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 endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency, first vein treated (36475).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for the professional services for immunotherapy. We 
decided that the Plan does not have to waive the cost share for the professional services for immunotherapy.  
 
You asked the Plan to waive the cost share for the professional services for immunotherapy provided on May 
11, 2022. You say that you should not be responsible to pay this. The Plan says that this cost sharing was 
charged correctly. 
 We decided that the Plan has to reduce the cost share the professional services for immunotherapy.  
 
The Plan says you must pay Medicare Part B drug coinsurance for the professional services for 
immunotherapy. The professional services for immunotherapy are considered a physician service, not a Part B 
drug to apply coinsurance. Therefore, we decided the Plan has to reduce the cost for the professional services 
for immunotherapy from $112.26 to $45. 
 
We also decided that the Plan does not have to waive the cost share for the professional services for 
immunotherapy. 
 
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 $45 for 
each covered visit or consultation in an outpatient location with a specialist. Therefore, we decided that the 
Plan does not have to waive the cost share for the professional services for immunotherapy. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on February 9, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an annual wellness visit. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 an annual wellness visit provided on February 9, 
2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 18, 2022 billed with 
codes 81162, 81201, 81292, 81295, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 18, 2022 billed with codes 81162, 81201, 81292, 81295, 81298, and 81317.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service February 27, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 74022. 
 
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 71045 
is a column II code to column I code 74022. 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 71045 billed for date of service February 27, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of radiofrequency ablation to 
the SI joint in the setting of failed back surgery syndrome and bilateral sacroiliac joint dysfunction has not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. This procedure is 
considered experimental/investigational due to the wide variation in efficacy reported in the peer reviewed 
literature. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 1, 2022. 
 
You asked the Plan to pay for the physician service. You say that prior authorization was not required for this 
service according to the plan representative. The Plan denied your request. The Plan says prior authorization 
was not obtained. The Plan also says the service in this case was not urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. There was no documentation showing the service in this case was 
urgent or emergent. Based on this information, we decided that Medicare rules for coverage of the physician service have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (G2023) provided on February 26, 
2022, outside of the United States. 
 
You asked the Plan to pay for the coronavirus testing. You say that this test was required in order to fly back to 
the United States. The Plan denied your request. The Plan says the coronavirus testing is not considered urgent 
or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 We looked at the file, and Medicare rules. The service you received outside of the United States is not 
considered urgent or emergent. Based on this information, we decided that Medicare rules for coverage of the 
coronavirus testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
coronavirus testing (G2023) provided on February 26, 2022, outside of the United States.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 8, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 
provided on May 2, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 81455 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on April 14, 2022. The documentation does not support the billed date of 
service. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
targeted genomic sequence analysis panel coded 81455 provided on May 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has not been walking and they need 
therapy so they can regain their strength so they can come home. The enrollee needs therapy and needs skilled 
care. The Plan denied your request. The Plan says this does not appear to meet Medicare 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage.  The enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollees medical needs surpass what 
SNF could provide. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. The enrollee's medical needs are being met in the current acute setting. 
 
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 transfer to the LTACH is not medically necessary at this time as it would not be 
clinically advantageous. Completion of treatment at the current facility 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on April 30, 
2021. 
 You asked the Plan to pay for the genetic testing. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that screening services such as pre-symptomatic genetic tests and 
services used to detect an undiagnosed disease or disease predisposition are not a benefit and are not covered. 
 
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. 
 
The test at issue in this appeal, the genetic testing, was requested solely for screening purposes. The genetic 
testing is considered a screening because the enrollee has no personal history of cancer, and no reported 
signs/symptoms of disease. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided to the enrollee on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says we 
cannot approve admission for long term acute care admission for removing the breathing machine (ventilator). 
This can be done at the current hospital and can be monitored for the heart rate. 
 
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 the enrollee was admitted to the acute care hospital with basal ganglia hemorrhage 
due to hypertension requiring intubation, trach placement, and complicated by bacteremia and was started on 
IV antibiotics. Recent notes describe the enrollee is now tolerating performance status trials, improving 
neurologically, with stable vitals, and has completed antibiotics. The enrollee appears to be more stable and 
improving and should only require short-term additional acute care hospital services that can safely be 
administered at the current facility until more appropriate for a lower level of care. The enrollee does not 
require services at the LTACH that are not already available at the current facility.  
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 the LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says the rules for SNF care have not been met. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. Furthermore, the 
enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in 
function, being limited by her cognition/dementia. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yutiq (J7314). 
 
You asked the Plan to pre-approve Yutiq. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not being prescribed for a 
medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Yutiq. Our reviewer says that the 
requested drug, Yutiq, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that Yutiq is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of Yutiq in the enrollee's clinical 
situation. Therefore, the reviewer found that the request for Yutiq 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 Yutiq have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Yutiq (J7314).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81479) provided on April 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the wrong date of service. 
 
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 payment for CPT code 81479 is not supported in the medical record. Specifically, the claim must 
be billed with the date that the specimen was collected. The records show that the specimen was collected on 
December 9, 2020. As such, the claim was billed with the incorrect date of service. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services (81479) provided on April 21, 2022.