Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (96413) provided on August 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a 
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. First, the Plan has not provided any instructions on how to send in a corrected 
claim. Second, the Plan has not provided a valid reason for why the chemotherapy drug itself would be 
covered, but the administration of the drug would not be covered. There are no edits between CPT 96413 and 
J0897, J9271, or J9217. Lastly, the Plan has given conflicting and varying reasons for denial and has not cited 
any specific statute in their denial. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services (96413) provided on August 5, 
2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Unna boot strapping rendered on April 22, 2021. 
 
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 procedure code 29580 is not separately payable. 
 
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 29580 is a column II code to column I code 29581. 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 the Unna boot strapping rendered on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a spinal fusion procedure. 
 
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says this 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 pay for the procedure. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the ZIP implant fusion device is experimental. More research is needed to demonstrate the safety and 
efficacy of this spinal fusion device. 
 
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 pay for a spinal fusion procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound coded 76641 provided on January 6, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are a duplicate. 
 
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 76641 is not supported in the medical record. Specifically, the documentation shows 
that this is a duplicate claim that has already been considered for payment by the Plan. No separate payment 
can be made. Based on this information, we decided that Medicare rules for coverage of the ultrasound have 
not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76641 
provided on January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camptosar (Irinotecan HCl). 
 
You asked the Plan to pre-approve Camptosar (Irinotecan HCl). You say that this drug is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there are other choices available for 
second line therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Camptosar (Irinotecan HCl). Our 
reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found 
The enrollee is a 76-year-old woman with a diagnosis of metastatic small cell carcinoma of the lung, with new 
lesions in the liver and bone developing. In this case, Camptosar is not FDA-approved for the enrollee's 
diagnosis. Furthermore, the documentation does not indicate that the use of Irinotecan HCl is supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Camptosar (Irinotecan HCl) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Camptosar (Irinotecan HCl).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says there are 
no therapy needs that are skilled at this time, and you are able to transition to a home exercise program. The 
Plan also says that more formal therapy is not needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the clinical documentation states that all physical therapy goals have 
either been met or partially met. Or reviewer also found that the goals that are partially met would not require a 
skilled therapist to assist in meeting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on February 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
interrogation device evaluation. We found no exception that would require the Plan to pay for the interrogation 
device evaluation. The records provided for review do not show that the service at issue was urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation 
provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that it is the responsibility of the nursing home to 
obtain prior authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
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 home health services provided on August 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
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. The Plan denied your request. The Plan says this 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental, and more research is needed. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 17, 
2022, to January 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you passed out when leaving your 
appointment for an injection. You say that you were taken to the hospital. You say that you were never told the 
exams would not be covered. You also say that you cannot afford to pay this bill. The Plan denied your request. 
The Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation did not indicate that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 17, 2022, to January 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on August 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that you rely on facility staff to verify eligibility 
and to obtain authorization from the enrollee's insurance company. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on August 17, 2021, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transport (A0427), ground 
mileage (A0425), supplies (A0398), and electrocardiogram, routine ECG with at least 12 leads (93005) 
provided on May 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the Medicare guidelines were followed. 
The Plan denied your request. The Plan says the claim was not billed as required by Medicare coding 
regulations. The Plan also says there was no primary Evidence of Benefits received. 
 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 directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the emergency ambulance transport (A0427), ground mileage 
(A0425), supplies (A0398), and electrocardiogram, routine ECG with at least 12 leads (93005) provided on 
May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
indication that the enrollee has tried and failed the required drug(s). Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that the plan's required drug(s) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on 
January 26, 2022. 
 
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 Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found screening tests without a valid medical diagnosis related to the health of the 
patient are not a benefit. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology services provided to the enrollee on January 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that 18 physical therapy, 18 occupational therapy, and 20 nursing visits were requested. The 
Plan has agreed to pre-approve 11 physical therapy and 6 occupational therapy visits. 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 you do 
not have documented skilled nursing or skilled therapy needs. As such, the requested home health skilled 
services are not shown to be medically necessary or reasonable. 
 
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 home health care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state services provided on 
December 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the determination of refractive state services. You say that the provider did not 
call the Plan to verify coverage. The Plan denied your request. The Plan says the services received are not a 
covered benefit when provided by an OON 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 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 the determination of refractive state services 
provided on December 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
 
 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 physician services provided on March 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a screening mammogram provided by an 
out-of-network (OON) provider on January 15, 2022. 
 
You asked the Plan to waive the coinsurance for the OON mammogram. You say that it was your 
understanding that mammograms were free. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 50% 
coinsurance for a screening mammogram with an out-of-network (OON) provider. 
 
Service Allowed Amount 50% Coinsurance (OON) 
Breast Tomography $55.49 $27.74 
Mammography $136.82 $68.41 
Total:  $96.15 You have been asked to pay $96.15, which is 50% of the allowed amount for the OON mammogram. The 
OON mammogram falls within the Breast Cancer Screening (Mammograms) 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 coinsurance for a screening mammogram provided by an out-of-network (OON) 
provider on January 15, 2022.