Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT 
code(s): 81161-59-90 x1 unit, 81411-90 x1 unit, 81439-90 x1 unit, and 81238-59-90 x1) provided on October 
18, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the claim 
should be paid. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT code(s): 81161-59-90 
x1 unit, 81411-90 x1 unit, 81439-90 x1 unit, and 81238-59-90 x1) provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on December 14, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for this item is correct, because the 
documentation submitted does not include proof of delivery of the specific item billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of a lumbar-sacral orthosis provided on 
December 14, 2020 have been met. The record does not include proof of delivery for the specific item billed on 
this claim. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on 
December 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 Livalo.  
 
Benefits for Livalo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on May 27, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on May 27, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285) and electrocardiogram, routine 
ECG with at least 12-leads; interpretation and report only (93010) provided September 16, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that the enrollee was admitted for further treatment. 
Please reprocess for payment. The Plan denied your request. The Plan says that this is a duplicate claim that has 
already been considered for payment. 
 
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. The Plan has not substantiated their reason to continue to deny the services. The 
Plan has denied that this claim is a duplicate of a claim already paid. However, the Plan has not provided the 
Explanation of Benefits showing payment of the services or specifying a valid denial. Therefore, we decided 
that the Plan has to pay for the emergency department visit (99285) and electrocardiogram, routine ECG with 
at least 12-leads; interpretation and report only (93010) provided September 16, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
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 the additional 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 additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. Ongoing skilled therapy is 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says step therapy rules for coverage of the requested drug have not been 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of an intravenous bisphosphonate before they will approve the requested drug, Prolia. 
Based on the medical records provided, there is no indication that you have 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 
you. 
 
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 treatment with Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81194, 81301, 
81436, 81455, and 81479 x2) provided on November 16, 2021. 
 
You asked the Plan to pay for molecular pathology testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not covered as 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. 
 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for 
coverage of molecular pathology testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular pathology testing (CPT code(s): 81194, 81301, 81436, 81455, and 81479 x2) provided on 
November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71260). 
 
You asked the Plan to pre-approve a CT of the thorax. You say that a repeat CT scan needs to be done in six 
weeks from April 26, 2022, which would be about June 9, 2022. The Plan denied your request. The Plan says 
imaging is not supported without results of prior chest imaging for comparison. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT of the thorax. Our reviewer says 
that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has a lung nodule. The enrollee had a CT scan done less than two months ago on April 12, 2022. Our 
reviewer also found that there is no specific clinical rationale for a repeat CT scan at this time. 
 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71260).
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 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 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 at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine; without 
contrast material (72148). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
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. Specifically, the Plan has not provided the medical records that pertain to this 
case. Our organization requested these records on June 23, 2022; however, the Plan did not provide a response.  
The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine; without contrast material 
(72148).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 booster vaccine administration (0054A) 
provided on February 8, 2022. 
 
You asked the Plan to pay for a COVID-19 booster vaccine. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the CPT Code Manual definition of code 0054A is "Immunization administration by intramuscular 
injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-
19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; 
booster dose." 
 
In this case, the billed CPT code is not supported because it is not paid when submitted on an outpatient claim. 
Based on this information, we decided that Medicare rules for coverage of a COVID-19 booster vaccine have not been met. Therefore, we decided that the Plan does not have to pay for a COVID-19 booster vaccine 
administration (0054A) provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 25, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the 
prior authorization and you would like the claim to be reprocessed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on October 25, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the item due to hemorrhoids. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided on December 13, 2021. 
 
You asked the Plan to pay for sedation services. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the records suggest that this service was rendered in an outpatient facility. CPT code 99153 has a 
professional/technical component indicator of 3. This means that this code has a technical component only. 
Payment for the technical component of the code is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for 
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99153) provided on December 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on January 19, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test purchased on January 16, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 test. You say that you received 3 different letters from 
the Plan, two denials and then 1 letter that says that reimbursements prior to February 15, 2022 will be covered. 
You also say that the information is confusing and feel you should be reimbursed. The Plan denied your 
request. The Plan says this was not a covered benefit at the time of purchase. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter (OTC) 
items and the at-home COVID-19 test is an OTC item. However, the Plan offers a supplemental benefit for 
over-the-counter home COVID-19 tests purchased after February 1, 2022. These tests were purchased on 
January 16, 2022, which is before this benefit went into effect. Therefore, we decided that the Plan does not 
have to pay for the at-home COVID-19 test purchased on January 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT PNS device neurostimulator (CPT code(s): 
C1778 and 64555). 
 
You asked the Plan to pre-approve the services. You say that you have completed all other treatments and they 
have been unsuccessful, the next option is the Peripheral Nerve Stimulator. The Plan denied your request. The 
Plan says the SPRINT PNS device does not fit the Medicare definition of an implanted peripheral nerve 
stimulator. 
 
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 services. Our physician reviewer 
found the request does not meet the criteria of the NCD regarding peripheral nerve stimulators. Therefore, the 
request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SPRINT PNS device neurostimulator (CPT code(s): C1778 and 64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wound debridement performed on 
January 25, 2022. 
 
You asked the Plan to waive the copayment for a wound debridement performed on January 25, 2022. You say 
that you feel this was incorrectly billed and there was no surgery done. The Plan denied your request. The Plan 
says enrollees pay a $325 copayment for each in-network outpatient hospital facility visit. 
 
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 $325 
copayment for Outpatient Surgery.  
 
 
 
 
 
 You have been asked to pay a $325 copayment for outpatient surgery. The billing code for a wound 
debridement is a surgical code. Wound debridement falls within the Outpatient Surgery 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 a wound debridement performed on January 25, 2022.