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

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit. Our reviewer says that Procrit 
is not reasonable and necessary for the enrollee. Our physician reviewer found Procrit is not FDA-approved for 
the treatment of normocytic anemia and hyperhomocysteinemia. The use of Procrit for the treatment of 
normocytic anemia and hyperhomocysteinemia is not supported by one of the major drug compendia or by 
clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our 
reviewer also found that the use of Procrit for the treatment of normocytic anemia and hyperhomocysteinemia 
is not indicated, supported or recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) and fundus photography (92250) 
provided on May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and fundus photography. You say that you want the Plan to cover 
these services. The Plan denied your request. The Plan says the services at issue were not approved of in 
advance and they were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) and fundus photography 
(92250) provided on May 3, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the placement of device in prostate for 
radiation therapy (55876) provided on November 22, 2021. 
 
You asked the Plan to pay an additional amount for the surgical service. You say that you have paid $5,338.23 
out-of-pocket. You say that you should not be responsible for the copayment in this case. The Plan denied your 
request. The Plan says the claim processed 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 $250 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $250 copayment for the surgical service. the surgical service falls within the 
Outpatient Surgery benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Additionally, the 
record shows that as of December 2021, the maximum out-of-pocket amount, $2,900, has not been reached. 
Therefore, we decided that the Plan does not have to pay an additional amount for the placement of device in 
prostate for radiation therapy (55876) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on March 29, 
2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid at the fee schedule rate for procedure 
code 81479. The Plan denied your request. The Plan says there is no indication that the requested service is 
medically reasonable and necessary in this clinical scenario. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the ordering psychiatrist must be board certified in psychiatry or neuropsychiatry. The ordering 
health care provider for this test is a advanced practice nurse, clinical nurse specialist not boarded in psychiatry 
or neuropsychiatry. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneSight test provided to the enrollee on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you are afraid to be admitted to the 
hospital without this advice. The Plan denied your request. The Plan says that records show you are not making 
self-adjustment to insulin regime according to blood glucose readings. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient mental health stay. 
 
You asked the Plan to pre-approve an inpatient mental health stay. The Plan denied your request. The Plan says 
that nursing and medical care is not needed twenty-four (24) hours per day. The Plan also says that the enrollee 
does not need to stay in this level of care to get better, and they are in no danger to harm themself or others if 
they are treated at a lower level of care. 
 
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 did not provide medical records for this case. We asked for these 
records, but they were not provided to us. Without this information we cannot determine if the requested 
service is not medically necessary. Consequently, the Plan has not substantiated their denial of payment in this 
case. Therefore, we decided that the Plan has to pre-approve an inpatient mental health stay.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are included in the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that this is necessary as you live in a 2-storey house. 
The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (81407, 81408, 81479) provided on March 4, 2021. 
 
You asked the Plan to pay for lab services. You say that these services are medically necessary to accurately 
assess the enrollee's current condition and the results of this testing will impact the enrollee's treatment and 
management. The Plan denied your request. The Plan says that cardiovascular disease screening tests are 
covered when ordered by the physician who is treating the beneficiary for the purpose of early detection of 
cardiovascular disease in individuals without apparent signs or symptoms of cardiovascular disease. The Plan 
says the codes which should be billed for cardiovascular disease screening are codes 80061, 82465, 83718, 
and/or 84479. The Plan says based on this information, the criteria for these services 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. Specifically, there is no indication that the services at issue are a cardiovascular 
disease screening test. A screening is provided when there are no symptoms or signs of a disease. The medical 
records in this case indicate that the enrollee has had ongoing symptoms/disease for several months. The testing 
in this case would be considered diagnostic. This means that the Plans argument regarding screening tests is 
not substantiated and does not apply in this case. The Plan has provided no other argument for denial. 
Therefore, we decided that the Plan has to pay for lab services (81407, 81408, 81479) provided on March 4, 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging/single-photon emission 
computed tomography (SPECT) imaging for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says a study similar to the one requested has already been approved. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found that there is a note in the chart showing the intent of ordering a nuclear medicine 
Cardiolite stress test, and presumably this is the exam that has been approved by the plan. However, no results 
are in the records. There is no evidence of an order or a plan for a SPECT myocardial perfusion study. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging/single-photon emission computed tomography (SPECT) 
imaging for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH 
services. The Plan denied your request. The Plan says that the member is receiving the care she needs in the 
hospital where she is now and there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
was admitted with hypoxia and acute on chronic metabolic encephalopathy in the setting of recent COVID-19 
pneumonia. The record indicates that the enrollee still requires acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator set in TTV-AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. There is documentation that this patient has 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. There is no documentation 
that the ventilator at issue in this case meets Medicare criteria for medically necessary and reasonable for this 
patient. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the expenses do not require separate 
authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved 
in advance. 
 
 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 items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to pay for the wound care supplies provided on February 28, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 13, 2021 billed with 
codes 81230, 81241, 81249, 81291, 91335, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 13, 2021 billed with codes 81230, 81241, 81249, 81291, 91335, and 81406.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that your laboratory performed all the tests that 
were ordered by the referring physician. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace provided on October 2, 2021. 
 
You asked the Plan to pay for the knee brace. You say that this was medically necessary and should be paid. 
The Plan denied your request. The Plan says there is no delivery ticket or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the knee brace provided on October 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme (F1Heme) comprehensive genomic 
testing (81455) provided on February 3, 2022. 
 
You asked the Plan to pay for F1Heme testing. You say that this service was medically necessary to determine 
the course of treatment for this enrollee. The Plan denied your request. The Plan says this testing is not 
medically necessary and is not likely to impact the clinical management of this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. At the time of services, CPT code 81455 was listed under the Group 
3 Paragraph of Article A56199. This means that at the time of services, code 81455 was considered 
automatically denied as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of F1Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne Heme (F1Heme) comprehensive genomic testing (81455) provided on February 3, 2022.