Persius/hicric huggingface dataset:
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 you are unable to move around on your own and 
you have no one at home to help you. The Plan denied your request. The Plan says the requested service is not 
medically necessary and therapy needs could be met at a lower level of care. 
 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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided May 9, 
2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that this test was medically 
necessary and is covered. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that evidence does not support combinatorial PGx 
tests. 
 
We looked at the file and Medicare rules. GeneSight Psychotropic testing is a combinatorial PGx test. This type 
of test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the GeneSight 
Psychotropic testing (81479) provided May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye exam (92012), an office visit (99205) and 
an ophthalmoscopy (92202) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with an ophthalmologist. You say that you have a large tumor 
between your brain and your eye. Your provider is asking you get a 2nd opinion prior to performing surgery. 
The Plan denied your request. The Plan says the request to be seen by an OON is not medically necessary since 
the Plan has in-network providers that can provide the service-item requested. The Plan also says that you were 
approved to see an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a medical eye exam (92012), an office visit (99205) and an ophthalmoscopy (92202) to be provided by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. The Plan denied your request. The Plan says that the enrollee does 
not meet the criteria for coverage. 
 
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 Leqvio. Our reviewer says that there is 
documentation that the Leqvio at issue in this case meets all Medicare criteria for medically reasonable and 
necessary for the enrollee. Our physician reviewer found there is documentation that the Leqvio at issue in this 
case meets all Medicare criteria for safe and effective for the enrollee. The provided records document "severe 
myalgias" from several statin medications with diagnoses of familial hypercholesterolemia and atherosclerotic 
heart disease. Our reviewer found that the enrollee is reported to "not tolerate statins at any dose." The enrollee 
has tried and failed Repatha due to side effects of severe rhinorrhea. Our physician reviewer also found that 
adequate documentation of severe statin intolerance is present in the provided medical records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have been met. Therefore, we decided that the Plan has to pre-approve 
Leqvio.  
 
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: Partially Favorable

 
We decided that the Plan has to waive the copayment for the nail trimming provided on June 7, 2022. We also 
decided that the Plan does not have to waive the copayment for the podiatry visit provided on June 7, 2022.  
 
You asked the Plan to waive the copayments for a podiatry visit and nail trimming provided from April 21, 
2022, to June 7, 2022. You say that you only went for nail trimmings. The Plan says that this cost sharing was 
charged correctly. 
 
 
 We decided that the Plan has to waive the copayment for the nail trimming provided on June 7, 2022.  
 
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 $0 
copayment for routine foot care.  
 
The Plan says that you must pay $41.39 for the nail trimming. Based on the Plan contract, however, you cannot 
be asked to pay more than a $0 copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for the podiatry visit provided on June 7, 2022. 
 
We also decided that the Plan does not have to waive the copayment for the podiatry visit provided on 
April 21, 2022. 
 
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 $45 
copayment for general podiatry visits.  
 
You have been asked to pay a $45 copayment for the podiatry visit. The podiatry visit falls within the podiatry 
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 the podiatry visit provided 
on April 21, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Imfinzi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism (procedure code 87798) provided to the 
enrollee on March 25, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 87798 (13 units) remains 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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report includes 
insufficient documentation to confirm a description of infectious agent detection by nucleic acid, and therefore 
cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. 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 infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified 
probe technique, each organism (procedure code 87798) provided to the enrollee on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on May 11, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on May 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided to the enrollee on March 22, 2022. 
 
You asked the Plan to pay for the colonoscopy. You say that this should be paid for. The Plan denied your 
request. The Plan says the code cannot be reported separately. 
 
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 45380 is "Colonoscopy, flexible; with biopsy, single or 
multiple." 
 
We asked our coder 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 colonoscopy. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the procedure report 
documents different sites of the colon. In this case, a polyp was removed in the distal descending colon, and a 
biopsy was performed in cecum. Therefore, modifier -59 would be appropriate in this case. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the colonoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for a colonoscopy provided to the enrollee on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sacituzumab Govitecan-hziy. 
 
You asked the Plan to pre-approve Sacituzumab Govitecan-hziy. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 Sacituzumab Govitecan-hziy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug as prescribed 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 as prescribed in the enrollee's clinical situation. No literature from Medicare approved cancer journals 
were submitted for review. The elements of the coverage criteria are not satisfied. 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 Sacituzumab Govitecan-hziy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Sacituzumab Govitecan-hziy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 6, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not indicate that four separate services were performed or 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. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 87640 was 
reported with CPT 87641 on the same date of service, same session. When reporting these two procedures, an 
appropriate modifier would be appended. Therefore, this procedure cannot be verified. In terms of CPT 81001, 
81003, and 81015, the laboratory report includes documentation of one urinalysis, and in this case several 
different urinalysis procedure were reported, and therefore this procedure cannot be verified. Laboratory report 
has insufficient documentation to support multiple urinalysis procedures, which results in inappropriate billing. 
 
We looked at this coder's review, the file, and Medicare rules. 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 laboratory services provided to the enrollee on September 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 8, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it was not 
necessary for you to be hospitalized. The Plan denied your request. The Plan says since you were not 
transported by ambulance, this service is not covered by your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that if you do not receive the rehabilitation, you will not 
be able to support yourself. You also say that you have no one to help you at home. The Plan denied your 
request. The Plan says the IRF services you are requesting 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a botox injection and chemodenervation 
provided on May 9, 2022. 
 
You asked the Plan to waive the cost share for a botox injection and chemodenervation. You say that you 
should not be responsible to pay this. 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 10% 
coinsurance for all other Medicare-covered Part B drugs. Your contract with the Plan also says you must pay a 
$45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
You have been asked to pay $247.60 for a botox injection and $45 for the chemodenervation. The total amount 
you owe is $292.60 ($247.60 + $45 = $292.60) The botox injection falls within the Medicare Part B 
prescription drugs benefit category.  The chemodenervation falls within the physician/practitioner services, 
including doctors office visits 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 cost share for the 
botox injection and chemodenervation provided on May 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental for the treatment of back pain. The services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.