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

 
We decided that the Plan does not have to pay for the drug testing services provided on June 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
 We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radionuclide stress test. 
 
You asked the Plan to pre-approve a radionuclide stress test. You say that the records provided support the 
need for the requested MPI services. The Plan denied your request. The Plan says there is no documentation 
that member has had an echocardiogram (ECG) or attempted a standard treadmill test, which is the standard of 
care. The Plan says that there were no contraindications noted in the clinical notes. 
 
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 a radionuclide stress test. Our reviewer 
says that a radionuclide stress test is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of dyspnea, but there is no record of chest pains or 
palpitations. The enrollees pre-test probability for an abnormal test is low and there is no documentation that 
his electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would 
support the need for radionuclide stress testing. 
 
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 radionuclide stress test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radionuclide stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the rental charges for the Trilogy 100 home ventilator for date 
of service January 1, 2019, billed with code E0466. 
 
You asked the Plan to waive the rental charges for the Trilogy 100 home ventilator. You say that you have been 
overcharged for the Trilogy 100 device because it is being incorrectly billed with E0466 when you are not 
using the additional features that justify this higher cost code. You are prescribed this for use as bilevel positive airway pressure (BiPAP) which should be coded as E0471, which is a much lower monthly payment and would 
become yours after a certain number of payments. You state that due to code E0466 you are being charged a 
higher monthly payment and never obtain ownership of the device. You feel that you should only be required 
to pay what would be owed for the E0471 code since these are the only features of the device that you use. The 
Plan denied your request. The Plan says you have been assessed the correct cost sharing for this device based 
on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related supplies 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 rental charges for the Trilogy 100 home ventilator for date of service January 1, 2019, billed with 
code E0466.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal lumbar epidural steroid injections (ESIs). 
 
You asked the Plan to pre-approve transforaminal lumbar ESIs. You say that the records provided support the 
need for the requested injection services. The Plan denied your request. The Plan says they have approved one 
transforaminal lumbar epidural steroid injection. The Plan says that two more transforaminal lumbar epidural 
steroid injections are not considered medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for certain 
indications.  
 
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 transforaminal lumbar ESIs. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a 
history of low back pain and lumbosacral radiculitis due to lumbar spondylosis and lumbar spinal stenosis. The 
enrollee reports numbness and leg weakness for the past three months. She was recommended to undergo a course of physical therapy and a series of 3 right L4-L5 transforaminal lumbar epidural steroid injections. In 
this case, there is no indication to prescribe a pre-determined series of epidural steroid injections. The review 
has determined that the requested injections are 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 transforaminal lumbar ESIs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transforaminal lumbar epidural steroid injections (ESIs).
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 the enrollee cannot tolerate the Bisphosphonate pills or 
intravenous due to severe gastroesophageal reflux disease and peptic ulcers. The Plan denied your request. The 
Plan says the criteria have not been met and it has not been demonstrated that it is medically necessary to make 
an exception for the enrollee. 
 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 Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternatives. The record indicates 
that the enrollee has severe gastroesophageal reflux disease and therefore has a contraindication to oral 
Bisphosphonate drugs. Gastroesophageal reflux disease is not a contraindication to the intravenous 
formulations. Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from the plan's preferred intravenous step one alternative. The elements of the 
coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be 
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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition of tooth to existing partial denture (D5650) for 
teeth # 6, 7, 10, 11 and 14. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says addition of tooth to existing partial denture is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested addition of tooth to 
existing partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve addition of tooth to existing partial denture (D5650) for teeth # 6, 7, 10, 11 and 14.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trintellix tablet 20mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a benefit exclusion. 
 
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 Trintellix tablet 20mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is necessary given the enrollee's recurrent 
hospitalizations, and excellent response to aggressive pulmonary measures The Plan denied your request. The 
Plan says there is an absence of a confirmed diagnosis of bronchiectasis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 device. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found the Volara system is not medically necessary. This device is a combination of positive end expiratory pressure, airflow oscillation, 
and nebulization. There are no convincing data to show this device is beneficial when used as an outpatient. In 
addition, the enrollee does not qualify for advanced airway clearance systems such as the vest system because 
there is no diagnosis of cystic fibrosis or bronchiectasis. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Volara system for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
patient was admitted for respiratory failure and COVID 19 infection. The patients medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
Additionally, there is not a reasonable expectation that the patient 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that your office does not carry or offer the preferred 
products. You also say that you only carry Euflexxa. The Plan denied your request. The Plan says there is no 
record showing the enrollee has tried one of the preferred drugs, or that the enrollee has medical reasons that 
prevent them from using the preferred drugs. 
 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 for the enrollee. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our 
reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the 
elements of the coverage criteria are not satisfied and the requested service cannot be 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483 and 64484). 
 
You asked the Plan to pre-approve epidural steroid injections (64483 and 64484). You say that the office note 
documents 80% relief. The Plan denied your request. The Plan says the member has not achieved 50% 
improvement in back pain for three months since last injection. 
 
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 epidural steroid injections (64483 and 
64484). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee had left transforaminal epidural steroid 
injections on October 21, 2021, with 80% pain relief but for a very short duration. The review has determined 
that the enrollee does not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections (64483 and 64484) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve epidural steroid injections (64483 and 64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Trilogy 100 home ventilator for date of service May 12, 
2020, billed with code E0466. 
 
You asked the Plan to pay for the Trilogy 100 home ventilator. You say that you have been overcharged for the 
Trilogy 100 device because it is being incorrectly billed with E0466 when you are not using the additional 
features that justify this higher cost code. You are prescribed this for use as bilevel positive airway pressure 
(BiPAP) which should be coded as E0471, which is a much lower monthly payment and would become yours 
after a certain number of payments. You state that due to code E0466 you are being charged a higher monthly 
payment and never obtain ownership of the device.  You feel that you should only be required to pay what would be owed for the E0471 code since these are the 
only features of the device that you use. The Plan denied your request. The Plan says you have been assessed 
the correct cost sharing for this device based on your contract. 
 
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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the Trilogy 100 ventilator. The Trilogy 100 ventilator falls 
within the durable medical equipment and related supplies 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 pay for the Trilogy 100 home ventilator for date of service May 12, 2020, billed with code E0466.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says the benefit only allows for 50 miles. 
 
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 one-way.  
 
We looked at your request, the records in the case file, and the rules. The requested trip is 80 miles, which is 30 miles over the limit.  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 
routine transportation mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Fulphila.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 20, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 27, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array (64555) and implantable neurostimulator (L8679). 
 
You asked the Plan to pre-approve a Auricular Nerve Stimulator. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this is a form of acupuncture, and therefore, not 
covered. 
 
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.  
 
 
 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, [ADJUDICATOR ENTER CASE SPECIFICS]. 
Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array (64555) and implantable neurostimulator (L8679).