Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee's current 
functional level does not need intensive therapies provided at an IRF. 
 
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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 25, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment. 
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 $25 
copayment for physician/practitioner services/Medicare-covered specialist.  
 
You have been asked to pay a $25 copayment for an office visit. However, you are only being charged $11.33 
which is less than the required amount. This item/service falls within the physician/practitioner 
services/Medicare-covered specialist 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 
an office visit provided on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 lab services provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27603 provided on October 28, 2021. 
 
You asked the Plan to pay for procedure code 27603. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says an assistant at surgery is not covered for this 
procedure code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 27603. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for 
procedure code 27603 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27603 provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has psoriatic arthritis and 
has been treated with methotrexate, meloxicam and sulfasalazine. The enrollee has not tried and failed the 
Plan's required drug, Stelara. The records do not show that the required drug would be contraindicated or less 
effective; therefore, Avsola is 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 Avsola.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile trip limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that a sales agent said 
you would have transportation coverage to your provider. The Plan denied your request. The Plan says the 
requested transport exceeds the Plan's mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50-miles of driving distance per one-way trip.  
 We looked at your request, the records in the case file, and the rules. The requested trip exceeds 50 miles of 
driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's 50-mile trip limit.  
 
Your complaint about potentially being provided misinformation by a sales representative is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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 Prolia. 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 history of osteoporosis. The documentation does not support that the enrollee has tried 
and failed an oral bisphosphonate drug (such as alendronate, ibandronate, or risedronate) and zoledronic acid. 
The documentation does not support that an oral bisphosphonate drug (such as alendronate, ibandronate, or 
risedronate) and zoledronic acid 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve Ziextenzo. 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 Ziextenzo. 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 rectal cancer and is on chemotherapy. The documentation does not 
support that the enrollee has tried and failed Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb) or 
Udenyca (pegfilgrastim-cbqv). The documentation does not support that Neulasta (pegfilgrastim), Fulphila 
(pegfilgrastim-jmdb) or Udenyca (pegfilgrastim-cbqv) 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 Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), and intraoral - complete series of radiographic images (D0210) provided on 
September 21, 2022. 
 You asked the Plan to pay for the dental services. You say that you expected to pay something for the services, 
but not the entire cost for the x-rays. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and therefore any remaining balance for these services are your 
responsibility. 
 
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. 
 
You have been asked to pay a total of $265. 
 
 
SERVICE 
DENTIST 
CHARGE 
ALLOWED 
AMOUNT 
INELIGIBLE 
AMOUNT 
 
DEDUCTIBLE 
% 
COVERED 
MEMBER 
RESPONSIBILITY 
D0210 $174 $98 $76 $98 50% $174 
D1110 $123 $69 $54 $0 100% $54 
D0120 $72 $35 $37 $0 100% $37 
TOTAL      $265 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and intraoral - 
complete series of radiographic images (D0210) provided on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain interferes with her 
quality of life. The Plan denied your request. The Plan says the requested procedure for low back pain has not 
been demonstrated in 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 the requested services. Our physician 
reviewer found that the enrollee is being treated for intervertebral disc degeneration of the lumbar region.  She 
presented with chronic bilateral low back and right knee pain. The pain continues to be in the back and has 
increased over the last month. There is pain on palpation over the bilateral facet joints L2-S1. There is pain 
with facet loading and bilateral lateral rotation. There is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested VIA Disc allograft procedure at L5-L6, in this case, 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VIA Disc allograft procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Polio and Hepatitis B vaccines rendered on June 29, 
2022. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the Polio and Hepatitis B vaccines rendered on 
June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone billed with code G2078 
for October 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028.  
 
We looked at the file and Medicare rules. The file shows that procedure code G2078 was not billed by a 
provider enrolled as an OTP. Therefore, we decided that the Plan does not have to pay for the take home supply 
of methadone billed with code G2078 for October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac computed tomography & angiography (CCTA). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CCTA is considered reasonable and necessary for the 
evaluation of suspected symptomatic coronary artery disease (CAD) and for the detection of structural and 
morphologic intra-and extra-cardiac conditions.  
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that at issue is the medical 
appropriateness and necessity of coronary CCTA in the clinical evaluation of this enrollee. The enrollee has no 
apparent cardiac signs or symptoms. Clinical guidelines for the use of coronary CCTA have not been met based 
on the review of the submitted clinical documentation. As a result, at this time coronary CCTA would not be 
considered medically reasonable and necessary in this enrollees 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac computed tomography & angiography (CCTA).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q5002, G0299, and G0157 billed for date of 
service July 8, 2021 to August 5, 2021. 
 
You asked the Plan to pay for procedure codes Q5002, G0299, and G0157. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the billed codes are not covered.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code G0299 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0299 is statutorily excluded from Medicare payment. Codes G0157 and Q5002 have a Status 
Indicator of E on the Physician Fee Schedule. This means that these codes are excluded from payment. Based 
on this information, we decided that Medicare rules for coverage of procedure codes Q5002, G0299, and 
G0157 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
Q5002, G0299, and G0157 billed for date of service July 8, 2021 to August 5, 2021.