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

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted doesn't meet the medical necessity guidelines for coverage. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the requires a trial of 
Zoledronic Acid before they will approve the requested drug.  In this case, the enrollee has not tried and failed 
this required drug. There is no documentation provided indicating that the plan's required drug would likely be 
less effective and/or likely have adverse effects for the enrollee. In addition, there is no history of an 
osteoporotic fracture. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from June 23, 2021, through 
July 1, 2021. 
 
You asked the Plan to pay for an inpatient admission. You say that you had lost 40 pounds because you were 
not able to swallow anything and no one in New Mexico could give you any direction on what could be done. 
You say you went to several doctors locally and they were not doing anything for you. You say this admission 
was not elective and was medically necessary. The Plan denied your request. The Plan says an approved prior 
authorization is required before services are rendered with an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 an inpatient admission provided from June 23, 2021, through 
July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second arthroplasty (25447-XU-51-RT) and a neuroplasty 
(64719-XU-51-RT) provided on March 11, 2021. 
 
You asked the Plan to pay for a second arthroplasty and a neuroplasty. You say that these codes can be paid. 
The Plan denied your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes and modifier. 
 
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 a second arthroplasty and a neuroplasty. Our 
reviewer says that the use of the billed codes and modifiers is not supported. Our physician reviewer found the 
operative report does not include documentation to confirm an arthroplasty as represented by 25447 was 
performed twice. The operative report also does not document the neuroplasty billed with 64719 was 
performed through a separate incision or by a different approach, and therefore would be inclusive to CPT 
64721. 
 
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 second arthroplasty and a neuroplasty have not been met. Therefore, we 
decided that the Plan does not have to pay for a second arthroplasty (25447-XU-51-RT) and a neuroplasty 
(64719-XU-51-RT) provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Decipher Prostate Assay (81542, 88381) provided on May 
6, 2021. 
 
You asked the Plan to pay for a Decipher Prostate Assay. You say that this testing was necessary to guide 
treatment. The Plan denied your request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a Decipher Prostate Assay. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the testing at issue can be approved up to unfavorable intermediate risk only before 
definitive treatment. The enrollee is high risk. 
 
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 Decipher Prostate Assay have not been met. Therefore, we decided that the 
Plan does not have to pay for a Decipher Prostate Assay (81542, 88381) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99214) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this request is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
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 
the office visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic services you had on May 
14, 2021. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that you had already met 
your out-of-pocket maximum, so there should be no copayment. The Plan denied your request. The Plan says 
you were charged this copayment correctly. 
 
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 $20 
copayment for chiropractic services.  
 
The records show that as of the date of this service, you had only met $70 towards your out-of-pocket maximum. You have been asked to pay a $20 copayment for the chiropractic services. 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 the chiropractic services you had on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services represented 
by code 99239 provided on February 16, 2021. 
 
You asked the Plan to pay for code 99239. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent 
providing services to the enrollee on the day of discharge. The progress note for February 16, 2021, does not 
note how much time was spent providing services to the enrollee. As such, the provided documentation does 
not support the billing of code 99239. Based on this information, we decided that Medicare rules for coverage 
of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge day management services represented by code 99239 provided on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on April 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on April 22, 2021.
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 May 26, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. 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 the 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 May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on June 29, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was a medical vision check (Puckering of Macula, Age-related nuclear 
cataract). Eye refractions are only covered by your plan if performed by a participating provider and performed 
as a routine screening. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-
covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on June 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement services 
coded 77002 provided on 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 
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. In this case, we have confirmed that code 77002 
for the fluoroscopic guidance for needle placement services is a column II code to column I code 01991. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
fluoroscopic guidance for needle placement services coded 77002 provided on
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Resin-based composite, one surface, anterior (D2330) resin-
based composite, one-surface posterior (D2391) provided June 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are retired and only receive social security 
to live. You did not know the cost was so high and do not have the money to pay for it. The Plan denied your 
request. The Plan says the benefit frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan contract says that 
restorations (fillings) are covered 2 procedure codes per calendar year. The records show that the Plan had 
already provided reimbursement for 2 fillings on May 6, 2021. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for Resin-
based composite, one surface, anterior (D2330) resin-based composite, one-surface posterior (D2391) provided 
June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular assessment testing screening panel 
provided on May 11, 2021 
 
You asked the Plan to pay for the cardiovascular assessment testing screening panel. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit. 
 
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. Cardiovascular risk assessment panels are only 
covered for certain indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular assessment testing screening panel provided on May 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee. 
 
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the member's left upper limb strength and function 
are adequate for the member to be able to control the power options using their own switches. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. The 
patient's strength and function in the upper extremities with the ability to feed himself indicates that the patient 
can control any power options through their own individual switches. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of an electronic connection.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on May 11, 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered when specific criteria 
are met. 
 
We looked at the file and Medicare rules. The records show that there is no documented prior biopsy or a 
significant interval increase in his prostate specific antigen (PSA) level. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the ConfirmMDx testing rendered on May 11, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 3-dimensional radiotherapy planning (code 77295) provided on 
May 24, 2021. 
 
You asked the Plan to pre-approve 3D radiotherapy planning. You say that this service was medically 
necessary in order to spare the enrollee's critical structures. The Plan denied your request. The Plan says that 
the denial of payment for this service is correct, because this test is not covered separately if it is contained in 
another authorized radiology procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 3D radiotherapy planning. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found code 77295 is billed for the generation of a 3-dimensional (3D) conformal plan. The 
billing of codes 77330, 77334, and 77295 together is not routinely denied nor considered controversial. This 
treatment is the standard of care for radiotherapy, and it is acceptable to separately bill for code 77295. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D radiotherapy planning have been met. Therefore, we decided that the Plan 
has to pre-approve 3-dimensional radiotherapy planning (code 77295) provided on May 24, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 
21, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
 
 
 
  
 
 
We looked at the file and Medicare rules. The file shows that billed procedure code 99282 (ER services) had 
been billed by a physician in the same group practice and previously paid. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the emergency room (ER) services rendered on September 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance (als or bls) oxygen and oxygen supplies (A0422) 
provided on May 28, 2021. 
 
You asked the Plan to pay for ambulance (als or bls) oxygen and oxygen supplies. The Plan denied your 
request. The Plan says the cost of oxygen and its administration in connection with and as part of the 
ambulance service is covered. Under the ambulance fee schedule (FS), oxygen and other items and services 
provided as part of the transport are included in the FS base payment rate and are not separately payable 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for 
ambulance (als or bls) oxygen and oxygen supplies (A0422) provided on May 28, 2021.
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 April 28, 2021. 
  You asked the Plan to pay for the occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. 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 the occupational therapy services have not been met. Specifically, the billing provider is a 
physician assistant, 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 April 28, 2021.