Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme 510MG/17ML solution (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from your prescriber that shows you have tried one of the 
preferred drugs (Ferrlecit, Infed or Venofer) and it has not worked, or that you have medical reasons that 
prevent you from using one of them. 
 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 medication. Our physician reviewer 
found the Plan requires a trial of drug Ferrlecit, Infed or Venofer, before they will approve the requested drug. 
In this case, you have not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme 510MG/17ML solution (CPT code Q0138).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided December 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed code. 
 
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 G0483 is definitive laboratory results for 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 
results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0483) provided December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meditation services you received on November 30, 2021. 
 
You asked the Plan to pay for the meditation services. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 receive 
wellness services from a qualified health club or fitness facility.  
 
The records show that you were provided online meditation services on November 30, 2021. These services are 
not covered under your wellness benefit. 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 pay for the meditation services you 
received on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan Hycela. 
 
You asked the Plan to pre-approve Rituxan Hycela. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Rituxan Hycela. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Rituxan Hycela is medically reasonable and necessary for you. The 
documentation does not support that the Rituxan Hycela is safe and effective 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 Rituxan Hycela have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituxan Hycela.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S8037 billed for date of service November 
30, 2021. 
 
You asked the Plan to pay for procedure code S8037. You say that you believe this is a valid procedure code. 
The Plan denied your request. The Plan says this is not a valid procedure code. 
 
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 S8037 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S8037 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S8037 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code S8037 billed for date of service November 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services on January 4, 2022. 
 
You asked the Plan to pay for the services. You say that the payments made are too low. The Plan denied your 
request. The Plan says this is a duplicate of a charge previously considered. 
 
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 codes 72100, 72072, and 72040 are not supported in the medical record. Specifically, it 
appears that these billed codes are a duplicate to other services already received. 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 additional imaging services on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) and the unlisted 
therapeutic procedure (97139) provided from January 5, 2022, through February 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided in this case are not 
payable. 
 
 
 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture treatment provided in this case was 
rendered solely by an independent acupuncturist. The provider who furnished the acupuncture was not under 
the supervision of a physician, physicians assistant, or nurse practitioner/clinical nurse specialist. Additionally, 
these services were not billed on the same date of a surgery. Therefore, we decided that the Plan does not have 
to pay for the acupuncture treatment (97810) and the unlisted therapeutic procedure (97139) provided from 
January 5, 2022, through February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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. 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 LTACH 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 16, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you asked for a referral and were told a referral 
was not necessary. The Plan denied your request. The Plan says the vision care in this case was provided for 
medical purposes rather than as a routine (non-medical) eye exam. Eye refractions are only covered when they 
are performed by a participating provider as part of a routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed by a provider in the Plans specified routine 
vendor network as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The documentation shows that the vision care provided on this date 
was a medical eye exam rather than a routine eye exam to evaluate changes in your vision and/or determine the 
need for eyeglasses or contact lenses. Based on this information, we decided that the Plan's rules for coverage 
of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a significant decrease in functional 
ability such that they cannot adequately recover in a less intensive setting. The Plan denied your request. The 
Plan says the services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for a stroke and urinary tract infection. Medical 
problems are stable. Our physician reviewer found there are no complex nursing or rehabilitation needs. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program in an inpatient rehabilitation facility.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder surgery. 
 
You asked the Plan to pre-approve shoulder surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 shoulder surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested complete 
replacement of the shoulder joint, 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 shoulder surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve shoulder surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.   
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services provided on December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
24, 2022, to February 22, 2022. 
 
You asked the Plan to pay for the services. You say that the services are coverable under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee did not receive daily skilled services on the dates of 
service in this case.  
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy 
needs. Daily skilled services were not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs, as a practical matter, could be provided at a 
lower level of care, like home, assisted living facility, long term care, etc. 
 
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 the skilled nursing facility (SNF) care provided from January 24, 2022, to February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you do need physical and/or 
occupational therapy, there is no documentation of a need for and ability to tolerate an intensive rehabilitation 
program. 
 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (H2011) provided on August 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
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. 
 
We find that CPT code H2011 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code H2011 is not valid for Medicare purposes. 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 the 
services (H2011) provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480) provided on February 21, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (G0480) provided on February 21, 2022 by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
5, 2022, to January 10, 2022. 
 You asked the Plan to pay for the services. You say that the enrollee no longer needed daily skilled services on 
the date of service in this case. The Plan denied your request. The Plan says the services are coverable under 
the Medicare Act. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy 
needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs were custodial and, as a practical matter, could be 
provided at a lower level of care, such as long-term care. 
 
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 the skilled nursing facility (SNF) care provided from January 5, 2022, to January 10, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the breast biopsy (19083) provided on October 19, 2021. 
 
You asked the Plan to pay for breast biopsy. You say that this service was denied incorrectly. While you agree 
that 77065 should not be paid separately, 19083 is the primary procedure and should be paid in full. The Plan 
denied your request. The Plan says that the Local Coverage Determination (LCD) criteria for this service are 
not met. 
 
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 states that the LCD criteria are not met for this service; however, the 
Plan does not elaborate or explain which criteria are not met. In addition, the LCD submitted by the Plan does 
not apply to the state where these services took place. No other argument was provided in support of the denial 
of these services, and the Plans argument is not substantiated in this case. Therefore, we decided that the Plan 
has to pay for the breast biopsy (19083) provided on October 19, 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.