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

 
We decided that the Plan does not have to pay for laboratory services (87186, 87641, 87500, 87651) provided 
on August 26, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration stating the 
lab requisition and lab results are attached as requested. The Plan denied your request. The Plan says the 
request does not meet Medicare rules as reasonable and 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 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 enrollee had a history of left kidney stone status post left stent exchange 8/12/2021. 
Urinalysis on 8/26/2021, had moderate blood, positive nitrites, and positive leukocyte esterase. Additional 
history included bladder cancer, BPH, nocturia, and urethral stricture. The Urinary Tract Infection Pathogen 
Panel was performed. Infectious Disease Society of America and Healthcare Infection Control Practices 
Advisory Committee (HICPAC), state standard of care for evaluation of urinary tract infection includes a 
urinalysis, followed by a urine culture and susceptibility studies Multiplex PCR is noninferior to urine culture 
for detection and identification of bacteria. Further investigation may show that the accuracy and speed of PCR 
to diagnose UTI can significantly improve the enrollee's outcome. The review has determined that the services 
at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87186, 87641, 87500, 87651) provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid, respiratory virus, 
12-25 targets (87633) provided on November 18, 2021. 
 
You asked the Plan to pay for the respiratory virus panel of 12-25 targets. You say that these services were 
medically necessary. The Plan denied your request. The Plan says this service is automatically denied as not 
medically necessary per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with more than five respiratory pathogens 
performed in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory virus panel of 12-25 targets have not been met. Specifically, the service at issue 
includes more than five respiratory pathogens and was performed in a Part B setting. Therefore, we decided 
that the Plan does not have to pay for infectious agent detection by nucleic acid, respiratory virus, 12-25 targets 
(87633) provided on November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you are often not able to get readings with finger 
pricks. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
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. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric emptying imaging study and gastric motility 
studies to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON gastric emptying imaging study and gastric motility studies. You 
say that the services being requested are medically necessary and supported by the records provided. The Plan 
denied your request. The Plan says the services being requested are available from a provider within their 
network. 
 
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 services with an OON provider. Therefore, we decided that the Plan does not 
have to pre-approve a gastric emptying imaging study and gastric motility studies to be provided by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DePuy Synthes ViviGen Allograft. 
 
You asked the Plan to pre-approve DePuy Synthes ViviGen Allograft. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been 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 pre-approve DePuy Synthes ViviGen Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Vivigen allograft is experimental in spine surgery. It is not needed. Iliac 
crest bone graft is gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DePuy Synthes ViviGen Allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve DePuy Synthes ViviGen Allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these tests were necessary and are supported in the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment (37765). 
 
You asked the Plan to pre-approve the varicose vein treatment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. 
 
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 varicose vein treatment. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found the documentation 
does not support medical necessity. The medical records and the surgeons appeal describe a request for stab 
phlebectomy of the lower extremities bilaterally.  However, the documentation does not describe significant 
symptoms in the left leg. 
 
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 varicose vein treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a varicose vein treatment (37765).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed height hospital bed (E0250). 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the enrollee needs elevation of the head more than 30 
degrees, no breathing problems, not at risk for aspiration, does not requires traction equipment. 
 
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 bed. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you do not have osteopenia, aspiration risk, or a need for positioning not available with a standard 
bed. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a fixed height hospital bed (E0250).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 28, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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 $375 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $375 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient facility 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 outpatient surgery provided on July 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010) provided October 
8, 2020. 
 
You asked the Plan to pay for the emergency visit. You say that your records indicate that the claim was filed 
within timely filing guidelines. Attached is documentation to establish the initial date of filing, as well as 
timely submission to the correct payer. The Plan denied your request. The Plan says the claim was submitted 
past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency visit was not filed until October 5, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99285) and electrocardiogram, 
routine ECG with at least 12 leads; interpretation and report only (93010) provided October 8, 2020.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee is taking oral antibiotics and does not receive daily wound 
care. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning 
at/near his baseline. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of 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 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: 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 had a urinary tract infection that affected your 
kidneys, and you cannot stand on your own. The Plan denied your request. The Plan says an IRF stay is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an 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 do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program.  While you may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has failed alternative medications and 
the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is 
self-administered and not covered under Part B. The Plan says that they do not administer Part D benefits for 
the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from May 9, 
2022, to May 28, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were admitted through the 
ER and should not have a copayment. 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 $200 per 
day for days 1 to 5 for inpatient services. You were hospitalized for 4 days, resulting in a $800 copayment for 
that stay. 
 
You have been asked to pay an $800 copayment for an inpatient stay. This item/service falls within the 
inpatient services 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 an inpatient stay 
provided from May 9, 2022, to May 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network services provided on August 17, 2022. 
 
You asked the Plan to pay for the out-of-network services. You say that the services provided were medically 
necessary and the attached medical records substantiate the request. 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 the out-of-network services provided on August 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and wound care provided on August 17, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that a primary care physician (PCP) referral is 
not required on this claim. You also say that this should be reprocessed for payment. The Plan denied your 
request. The Plan says the enrollee's PCP did not refer them for the services in this case. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit and wound care provided on August 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313, 
E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has sufficient upper body strength and mobility to manage the standard 
switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2313, E2377).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on July 05, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that this should be covered. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription drugs 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. You have been asked to pay $425.81 which is 20% of the allowed amount for the injections. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on July 
05, 2022.