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

 
We decided that the Plan has to pre-approve ultrasonic guidance (G6001) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that that there is not enough evidence in the medical literature to show that this 
service has a role in improving outcomes in this 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 pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Ultrasound allows 
for high-resolution imaging of the skin in real-time to guide superficial radiotherapy. Our physician reviewer 
found that the enrollee's condition meets criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan has to 
pre-approve ultrasonic guidance (G6001) 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member does not require close supervision by a physician. 
 
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. The 
enrollee does not have complex or intensive rehabilitation needs. He is functioning at a home care level to 
outpatient level of rehabilitation.  The enrollee does not require frequent physiatry oversight. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF care. 
 
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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on March 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that these services were approved. The Plan denied 
your request. The Plan says these services were rendered by an OON 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 
physical therapy services provided on March 8, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C for the enrollee. 
 
You asked the Plan to pre-approve Gamunex-C. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred product. 
 
 
 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 Gamunex-C. Our reviewer says that 
Gamunex-C is not medically reasonable and necessary. The patient has not tried and failed Privigen. The plan's 
required drug is not likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer found that the enrollee's condition does not meet step therapy criteria for Gamunex-C. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on February 11, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says these services were not authorized and are not payable by the 
Plan. 
 
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 
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 physical therapy (PT) services provided on 
February 11, 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 next generation sequence testing provided on February 2, 
2022. 
 
You asked the Plan to pay for the next generation sequence testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that contain testing for the FANCC gene 
are specifically not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the testing provided included testing for 
the FANCC gene. This means the entire panel is not covered. Based on this information, we decided that 
Medicare rules for coverage of the next generation sequence testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the next generation sequence testing provided on February 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on February 15, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. The Plan denied your request. The Plan says these services were 
rendered by an OON provider. The Plan also says these services were not authorized and are not payable by the 
Plan. 
 
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 
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 physical therapy (PT) services provided on 
February 15, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the $300 copayment for inpatient hospital services on 
February 15, 2022. 
 
You asked the Plan to reduce the $300 copayment for inpatient hospital services. You say that you were 
admitted due to complications, and therefore you should only be responsible for an outpatient surgery 
copayment. The Plan denied your request. The Plan says you must pay a $300 copayment each time you are 
admitted to a hospital and that you will not pay more than $900 for inpatient hospital covered services per 
calendar year. 
 
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 $300 
copayment for Inpatient Hospital Care.  
 
You have been asked to pay a $300 copayment for inpatient hospital services. Inpatient hospital services fall 
within the Inpatient Hospital Care 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 reduce the $300 copayment for inpatient hospital services on February 
15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM) 
supplies for the enrollee. 
 
You asked the Plan to pre-approve CGM supplies. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 the enrollee does 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 CGM 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 
continuous glucose monitor (CGM) supplies for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 74018 is bundled into payment for code 74019. 
 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 74018 
is a column II code to column I code 74019. 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 procedure code 74018 billed for date of service February 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen therapy. 
 
You asked the Plan to pre-approve home oxygen therapy. 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 home oxygen therapy is reasonable and necessary 
only if 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 home oxygen therapy. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found home oxygen is not medically 
necessary. This enrollee has diagnoses of lung cancer, breast cancer, and radiation pneumonitis. The records 
consist of a hematology oncology visit from June 3, 2022, when the oxygen saturation (SpO2) was normal at 
98%. Medicare criteria for supplemental oxygen are not 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 home oxygen therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen therapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there are no services offered at an SNF that 
are not offered at an inpatient rehabilitation facility. Admission to an SNF for inpatient skilled rehabilitation 
services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 20, 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 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. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on November 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) admission 
and services provided from November 24, 2021, to December 21, 2021. 
 
You asked the Plan to waive the copayment for SNF care. You say that you would like the copayment for the 
additional days waived for these services because you had COVID-19. The Plan denied your request. The Plan 
says this claim was processed correctly, and your share of the cost for these covered services has been assessed 
in accordance with your contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for days 21-100 for a stay in a skilled nursing facility. There is a $0 copayment required for days 1-
20. 
 
You have been asked to pay a $741.40 copayment for a 27-day SNF admission. The first 20 days were 
processed with no copayment required, and days 21-27 had a $160 copayment applied ($160 x 7 = $1,120). 
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 skilled nursing facility (SNF) admission and services 
provided from November 24, 2021, to December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on January 11, 2022. 
 
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 FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology, GeneSight psychotropic 
genetic testing (81479) provided May 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
original determination and coverage of the GeneSight Psychotropic test as medically necessary. 
 The Plan denied your request. The Plan says the testing not medically necessary because there is no medical 
record to indicate the physician intended to order this testing nor that the required criteria were met. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that per the provider, the enrollee has generalized anxiety 
disorder and major depressive disorder. The enrollee has failed psychiatric medication (Zoloft). The enrollee 
underwent GeneSight Psychotropic which is a pharmacogenomic test that analyzes clinically important genetic 
variations that may affect a patients response to psychiatric medications. In this case, the request is not 
medically necessary because there is no medical record to indicate the physician intended to order this testing 
nor that the required criteria were 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology, GeneSight psychotropic genetic testing (81479) 
provided May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement, arterial system (36247) 
provided December 29, 2021. 
 
You asked the Plan to pay for the procedure. You say that please consider this claim and provide you the 
reimbursement for this procedure performed. The Plan denied your request. The Plan says not eligible for 
payment due to modifier GZ. 
 
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 36247 is selective catheter placement, arterial system, 
initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular 
family. 
 
We find that CPT codes 36247-GZ and 36247-59-GZ are not supported in the medical record. Specifically, the 
claim was billed with the GZ modifier. The GZ modifier means that the item or service is expected to be denied 
as not reasonable and necessary. Claims billed with the GZ modifier is not eligible for payment. Based on this 
information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement, arterial system (36247) provided 
December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine 
received on March 2, 2022. 
 
You asked the Plan to pay for the CPAP machine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item received is not a covered benefit when purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP machines are only covered when rented 
and not purchased.  
 
We looked at the file and Medicare rules. Review of the file shows that you purchased the CPAP machine. 
Based on this information, we decided that Medicare rules for coverage of the CPAP machine have not been 
met. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) machine received on March 2, 2022.