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

 
We decided that the Plan does not have to pay for the home visit for the evaluation and management of an 
established patient (99350) rendered by the out-of-network (OON) provider on January 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the home visit for the evaluation and management of an established patient (99350) 
rendered by the out-of-network (OON) provider on January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on September 28, 2020. 
 
You asked the Plan to pay for occupational therapy services. You say that plans are required to pay non-
contract providers at the preferred provider rate when services are not available from preferred providers in the 
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The 
Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on September 28, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx test provided to the enrollee on 
October 10, 2020. 
 
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 that the testing was already performed on the enrollee's cancer without a new diagnosis of 
primary cancer reported. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found per the National Comprehensive Care Network (NCCN) Guidelines tumor/somatic molecular profiling is 
recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer therapy 
to identify uncommon mutations. Consider specifically testing for  potentially actionable somatic findings 
including, but not limited to: fusions (ALK, NRG1, NTRK, ROS1, FGFR2, RET), mutations (BRAF, 
BRCA1/2, KRAS, PALB2), amplifications (HER2), microsatellite instability (MSI), and/or mismatch repair 
(MMR) deficiency. Testing on tumor tissue is preferred; however, cell-free DNA testing can be considered if 
tumor tissue testing is not feasible. This patient has advanced pancreatic cancer. The service was reasonable 
and 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 services have been met. Therefore, we decided that the Plan has to pay for 
the FoundationOne Liquid CDx test provided to the enrollee on October 10, 2020.   
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that the patient significantly benefited from 
this service. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 medical services provided on August 11, 2021, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve cervical bilateral facet joint injection. 
 
You asked the Plan to pre-approve cervical bilateral facet joint injection. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary when specific criteria are met. 
 
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 cervical bilateral facet joint injection. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the request is 
medically reasonable and 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 cervical bilateral facet joint injection have been met. Therefore, we decided that 
the Plan has to pre-approve cervical bilateral facet joint injection.  
 
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: Favorable

 
We decided that the Plan has to pay for the office visit (99214) rendered by the out-of-network provider on 
January 12, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the service has been denied because it 
was rendered by an out-of-network provider, without prior authorization. 
 
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 forwarded the Evidence of Coverage (EOC) contract 
for the year 2021. However, this service was rendered in the 2022 calendar year. It is the burden of the Plan to 
substantiate their denial with evidence. The Plan has not substantiated their denial so we must find in your 
favor. Therefore, we decided that the Plan has to pay for the office visit (99214) rendered by the out-of-
network provider on January 12, 2022.  
 
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 the special anesthesia service (99100) provided on June 16, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the documentation should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says procedure code 
00914 has been overturned and procedure code 99100 remains denied as bundled services are not eligible for 
separate reimbursement.  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography 
with computed tomography transmission (PET/CT) perfusion study. 
 
You asked the Plan to pre-approve myocardial imaging, PET/CT perfusion study. 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 follows Medicare rules. Medicare rules say that cardiology non-emergent outpatient stress testing is 
covered when specific criteria are met. 
 
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 myocardial imaging, PET/CT perfusion 
study. Our reviewer says that the services are not medically necessary. Our physician reviewer found other 
modalities of stress testing have not been performed. Guidelines do not support the use of cardiac PET imaging 
in this role. As a result, at this time cardiac PET scanning would not be considered medically reasonable and 
necessary in your clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial imaging, PET/CT perfusion study have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography with 
computed tomography transmission (PET/CT) perfusion study.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and services to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Confirm MDx test provided to the enrollee on December 
30, 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 National Comprehensive Cancer Network (NCCN) has recommended other biomarkers be 
done to further evaluate the risk if the biopsy is negative. 
 
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 the testing was provided immediately after first biopsy without results of such biopsy having been 
available to review prior to ordering Confirm MDx. Without the results of the most recent biopsy and without 
documentation suggesting the patient was being considered for a second biopsy for any reason, this request for 
Confirm MDx will be considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Confirm MDx test provided to the enrollee on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
December 13, 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 plan has not received the required clinical records to support the medical necessity of this 
service. 
 
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 pain management services provided to the enrollee on December 13, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the services are considered 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the request is not considered medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intraosseous basivertebral nerve ablation.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a personal emergency response system (PERS) service. 
 
You asked the Plan to pre-approve PERS service. You say that this device remains medically necessary for 
your condition. The Plan denied your request. The Plan says that coverage is being denied for the PERS system 
because there is no evidence provided of an unsteady gait or recent history of falls. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone emergency systems and other 
emergency communications systems do not serve a diagnostic or therapeutic purpose and are therefore not 
covered by Medicare. However, the Plans contract provides coverage for emergency alert systems that 
exceeds Medicare. This system is covered provided that the member has a relevant diagnosis such as a history 
of falls, unsteady gait, or balance disorder. 
 
We looked at the file and Medicare rules. The record indicates that the enrollee was recently admitted to the 
emergency room with dizziness and visual disturbances in February 2022. The diagnosis for this admission was 
listed as vertigo. Coverage for the PERS system is made when the enrollee has a relevant diagnosis 
according to the Plans contract. Based on the enrollees recent emergency room stay for vertigo and ataxia, it 
would appear the enrollee has a relevant diagnosis of a balance disorder as required for coverage of PERS 
servcies. Based on this information, we decided that Medicare rules for coverage of PERS service have been 
met. Therefore, we decided that the Plan has to pre-approve a personal emergency response system (PERS) 
service.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 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 Hyalgan. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the records provided do not indicate that 
the enrollee has tried and failed the required drugs, Orthovisc or Supartz FX. The reviewer found that 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. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone Gel. 
 
You asked the Plan to pre-approve Testosterone Gel. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Testosterone Gel.  
 
Benefits for Testosterone Gel 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a low dose CT scan of the lungs/chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for 
enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee fulfills all of 
the needed criteria for this scan. The cough is productive and is due to post nasal drip rather than likely from 
the lungs. The weight loss has not been quantified. The patient should have lung cancer screening, as the chest 
x-ray has been negative. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a low dose CT scan of the lungs/chest for the enrollee.  
 
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.