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 need respiratory and therapy services. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. 
The Plan denied your request. The Plan says the Medicare rules 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 enrollee's records show they are not being treated with three or 
more daily administrations of insulin or an insulin pump. Based on this information, we decided that Medicare 
rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the therapeutic CGM and supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 18, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this claim needs to be reprocessed. The Plan denied your request. The Plan says these services are included in 
Part A skilled nursing facility (SNF) payment. The Plan also says that the provider did not bill as required by 
Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation and related ambulance 
services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services 
by the supplier. 
 We looked at the file and Medicare rules. Specifically, these services were billed with modifier NN, and the 
Plan confirmed both were covered Part A stays, so this would be payable by the transferring SNF, not the Plan. 
Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance 
transportation and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on March 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressings on 
tooth #3, 4, 5, 12, and 16 (D7922). 
 
You asked the Plan to pre-approve dressing placements. You say that to avoid bleeding after having the 
extractions done the dentist wants to apply a biological dressing. The Plan denied your request. The Plan says 
that the placement of intra-socket biological dressings (D7922) is not covered by your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
placement of intra-socket biological dressings on tooth #3, 4, 5, 12, and 16 (D7922).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that to date there are no compelling data to suggest that proton beam therapy is superior to or 
more beneficial than other standard approaches. The generally accepted standard of care for prostate cancer is 
to only offer proton beam therapy on clinical trials and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kesimpta. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules 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 pre-approve Kesimpta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing provided to the enrollee on May 12, 
2022. 
 You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient's records did not clearly show a prior urine drug screening with inconsistent or suspicious 
results to justify confirmation testing for multiple drug classes unrelated to this clinical case, let alone for any 
of the drug classes. There was no report of suspected abuse or misuse of medications or other indication for 
definitive testing. Therefore, this request for such will be considered not 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive drug testing provided to the enrollee on May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an allograft for spinal surgery (20931) billed for date of 
service February 22, 2022. 
 
You asked the Plan to pay for an allograft. You say that you have provided documentation to support the 
service billed. The Plan denied your request. The Plan says the available records do not support the service 
billed. 
 
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 20931 is "Allograft, structural, for spine surgery only 
(List separately in addition to code for primary procedure)." 
 
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 an allograft. Our reviewer says that the CPT code at issue 
does not meet criteria for payment. Our reviewer found that the available medical records do not give 
appropriate documentation of the allograft. The documentation does state that there was a fusion with L4 and 
L5 with both allograft and autograft material; however, that statement alone does not document with definitiveness that an allograft was used in this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an allograft have not been met. Therefore, we decided that the Plan does not 
have to pay for an allograft for spinal surgery (20931) billed for date of service February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for home health services on March 28, 2022, to 
April 18, 2022. 
 
You asked the Plan to waive the copayment for home health services. You say that you would like to appeal the 
cost share. 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 40% 
coinsurance for home health services. The total cost share is $300. 
 
You have been asked to pay a 40% coinsurance for home health services. This item/service falls within the 
home health agency care 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 home health 
services on March 28, 2022, to April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision services on July 22, 2022. 
 
You asked the Plan to waive the copayment for vision services. You say that you would like to appeal the cost 
share. 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 $20 
copayment for each Medicare covered eye exam and a 20% coinsurance for vision services.  
 
You have been asked to pay a $20 copayment for each Medicare covered eye exam and a 20% coinsurance for 
vision services. This item/service falls within the Medicare Part B prescription drugs and Vision care benefit 
categories. 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 vision services on July 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from April 15, 2021, 
to June 1, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reconsidered for payment. The Plan denied your request. The Plan says you must bill services within 12 months 
of the date of service. The Plan also says that the evidence supplied on appeal does not warrant a good cause 
exception under Medicare and Plan rules. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health care services was not filed until June 4, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the home health care services provided from April 15, 2021, to 
June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy, flexible; diagnostic, including collection of 
specimens (s) by brushing or washing, when performed (separate procedure) (45378) 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) 
esophagogastroduodenoscopy, flexible, transoral; snare lesion removal (43251) provided June 3, 2022. 
 
You asked the Plan to pay for the outpatient procedure. You say that this medical service was necessary, 
provided by an in-network provider and rendered for reasonable cost. You are hopeful the Plan will still accept 
the claim and make some payment pending a determination of responsibility by another insurance company. 
The Plan denied your request. The Plan says an explanation of benefits is needed before this claim can be 
considered. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
outreach and confirmed that the Primary insurance has not been billed. As the secondary insurer, the Plan 
cannot be held responsible for the outpatient procedure until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the colonoscopy, flexible; diagnostic, 
including collection of specimens (s) by brushing or washing, when performed (separate procedure) (45378) 
esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) 
esophagogastroduodenoscopy, flexible, transoral; snare lesion removal (43251) provided June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic cardiovascular screening testing provided on January 
5, 2022. 
 
You asked the Plan to pay for genetic cardiovascular screening testing. You say that the requested services 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested screening 
testing is not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that genetic testing for hereditary cardiovascular disease will be 
considered medically reasonable and necessary if the criteria listed in the Medicare rules section of this letter 
have been met. 
 
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 genetic cardiovascular screening testing. Our 
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician 
reviewer found that the services at issue assess the presence of pathogenic or likely pathogenic variants in 
genes known to be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to 
support its role in the enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic cardiovascular screening testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic cardiovascular screening testing provided on January 5, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy guidelines were not followed. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Pamidronate or zoledronic acid before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xgeva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the sales tax (S9999) and the compression 
stockings (A6549) purchased on July 12, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
sales tax (S9999) and the compression stockings (A6549) purchased on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 11, 2022, billed 
with codes 81225, 81226, 81227, 81401, 81231, 81240, 81241, 81291, 81328 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and should be 
paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. In addition, this claim was submitted with an incorrect place of service code. 
 
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. 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. This was an NGS panel that was not billed with a single panel code 
as required. In addition, this claim was billed with the laboratory POS code, but 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 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 February 11, 2022, billed with codes 81225, 81226, 81227, 81401, 
81231, 81240, 81241, 81291, 81328 and 81335.