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

 
We decided that the Plan does not have to pay for procedure code G0483 billed for services provided on March 
7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is valid. The Plan denied your request. 
The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not 
show that at least 22 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0483 billed for services provided on March 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 29, 2022. 
 
  You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would like this claim to be reprocessed. The Plan denied your request. The Plan says this claim was 
correctly denied, as the enrollee was in hospice at the time of service, and this is not the Plans responsibly as 
this is payable by original fee-for-service Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the Plan needs to cover the claim and you are 
expecting the denied claim to be reprocessed for payment. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 provided on July 28, 2022, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is experimental. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term 
use. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity angiography and revascularization. 
 
You asked the Plan to pre-approve the lower extremity angiography and revascularization. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
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 lower extremity angiography and revascularization. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
while the patient has a history of claudication, the documentation does not confirm the presence of severe 
disease, nor has there been a trial of medical therapy and risk factor management. In summary, there is 
insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization in this patients 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 the lower extremity angiography and revascularization have not been met. 
Specifically, there is insufficient documentation to support the medical necessity for lower extremity 
angiography and revascularization in this patients clinical management. Therefore, we decided that the Plan 
does not have to pre-approve the lower extremity angiography and revascularization.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee needs a bone-building agent. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug. 
 
 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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of Forteo before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plans required drug would likely be less effective or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an insertion of breast implant, provided on April 8, 2022. 
 
You asked the Plan to pay for an insertion of breast implant. You say that the service should be covered. The 
Plan denied your request. The Plan says the assistant surgeon is never allowed with the procedure code billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 19340. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for an 
insertion of breast implant have not been met. Therefore, we decided that the Plan does not have to pay for an 
insertion of breast implant, provided on April 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
December 19, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
December 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test identifies possible treatment options. The 
Plan denied your request. The Plan says the claim did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
 We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Left Knee Genicular Nerve Block. 
 
You asked the Plan to pre-approve the Left Knee Genicular Nerve Block. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 Left Knee Genicular Nerve Block. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are limited large-scale, long-term references showing the safety and 
efficacy of the requested injection in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 Left Knee Genicular Nerve Block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Left Knee Genicular Nerve Block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that the denial of payment is incorrect. The Plan denied 
your request. The Plan says the services were not billed as required. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The services were not billed with a modifier suitable for payment. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
cervical spinal canal and contents (72141). 
 
You asked the Plan to pre-approve an MRI scan of the cervical spine. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 pre-approve an MRI scan of the cervical spine. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented red flag in the medical records to mandate immediate MRI of the 
cervical spine. A report of a computed tomography (CT) scan of the lumbar spine dated October 12, 2022, 
showed severe stenosis at L4-5; however, the results of this exam are not addressed in the submitted records. 
There is an order for referral to physical therapy which apparently has not yet been attempted. 
 
 
  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 MRI scan of the cervical spine have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI scan of the cervical spinal canal and contents (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a medical eye examination (92004), frames (V2020), 
polycarbonate lenses (V2784), and a vision item or service (V2799) provided from June 20, 2022, to June 28, 
2022. 
 
You asked the Plan to pay for a medical eye examination (92004), frames (V2020), polycarbonate lenses 
(V2784), and a vision item or service (V2799). You say that you called the Plan and were told that your plan 
was a reimbursement plan, and you should file the claim with a vendor. You also say that your claim was 
denied because it is not a reimbursement plan. The Plan denied your request. The Plan says services from non-
participating providers are not covered under your plan unless they are authorized before the services are 
provided. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when seen by a network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that services from non-participating providers are 
not covered under your plan unless they are authorized before the services are provided. The record shows the 
services you received were from a non-participating provider. Based on this information, we decided that the 
Plan's rules for coverage of a medical eye examination (92004), frames (V2020), polycarbonate lenses 
(V2784), and a vision item or service (V2799) have not been met. Therefore, we decided that the Plan does not 
have to pay for a medical eye examination (92004), frames (V2020), polycarbonate lenses (V2784), and a 
vision item or service (V2799) provided from June 20, 2022, to June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from April 
21, 2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you feel that the 
copayments should be paid 100%. The Plan denied your request. The Plan says this cost sharing was charged 
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 in-network outpatient rehabilitation services/physical therapy.  
 
You have been asked to pay a $20 copayment for physical therapy visits. You are being asked to pay $60 ($20 
x 3 visits = $60). This item/service falls within the in-network outpatient rehabilitation services/physical 
therapy 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 copayment for physical therapy visits 
provided from April 21, 2022, to April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 
25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you would like to appeal 
this service. The Plan denied your request. The Plan says prior authorization was not obtained before the 
service was rendered to the enrollee. 
 
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 the domiciliary or rest home visit (99336) 
provided on June 25, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from June 23, 2022, 
to June 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. The enrollee presented to the emergency department after 
three episodes of hematemesis, and had a PEG tube for nutritional support. The enrollee was evaluated by 
gastroenterology and then admitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from June 23, 2022, to June 28, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get into an IRF to be able to return home 
safely. The Plan denied your request. The Plan says an IRF is not medically necessary, and your needs can be 
met in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and do not require close supervision for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While you can benefit from 
physical and occupational therapy, your needs can be safely provided in an alternate level of care such as a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.