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

 
We decided that the Plan does not have to pre-approve the Prolia injection (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan requires notes that show they have tried and failed at least one 
(1) plan-approved medicine first (bisphosphonate - alendronate, risedronate, or ibandronate). The Plan states 
the enrollee's doctor's notes do not show they have tried and failed the needed plan-approved medicine. The 
Plan states the enrollee's doctor's notes do not show why they cannot take the plan-approved medicine.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the Plan requires a trial of drug bisphosphonate - alendronate, risedronate, or ibandronate, before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is 
no documentation provided indicating that the plans 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Prolia injection (CPT code J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 the lab services provided on November 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the requested services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says you do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that your last injection was provided on April 22, 
2022. A repeat injection is covered when two months or longer has passed since the last injection. Based on 
this information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the test does not 
meet Medicare coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that 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. 
 
The file shows that the enrollee received a hereditary cardiovascular gene panel. We looked at the file and 
Medicare rules. The claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. The screening panel was not ordered for a specific medical problem. 
Medicare does not cover this testing for screening purposes. 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 September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99291) provided August 26, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the primary insurer is responsible for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the physician services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for physician services (99291) provided August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray provided on December 7, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the procedure was rendered in the appropriate place of 
service. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. The records show that at the time the x-ray was provided, the enrollee was 
receiving inpatient hospital care. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the hip x-ray provided on December 
7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services (CPT code(s) 62368, 62369, 
G0088, and S9328) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from 
your location that can provide this service when medically necessary. 
 
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. 
 
For CPT code S9328 has a status code I, which is not valid for Medicare purposes. Medicare uses another 
code for reporting of and payment for these services. Your request for this service as your provider has coded it 
is not a covered benefit under your Medicare and the health plan. We suggest your doctor re-submit the request 
with an appropriate code. Furthermore, the requested provider in this case is not a network provider with the 
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We 
found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that 
the Plan does not have to pre-approve the home health services (CPT code(s) 62368, 62369, G0088, and 
S9328) to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac rehabilitation (rehab) services provided from 
September 20, 2021, to September 28, 2021. 
 
You asked the Plan to pay for the cardiac rehab services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the provided documentation does not indicate that the services 
were medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab 
programs. The services must be provided in a doctors office or an outpatient hospital setting.  
 
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 cardiac rehab services. Our reviewer 
says that the cardiac rehab services were not medically necessary. Our physician reviewer found cardiac 
rehabilitation is medically necessary in patients with certain events such as acute myocardial infarction or 
revascularization. The reviewer found that the provided documentation does not indicate that the cardiac 
rehabilitation is not clinically warranted and not considered medically reasonable or necessary in the 
management of this 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 the cardiac rehab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the cardiac rehabilitation (rehab) services provided from September 20, 2021, to 
September 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) visit in your home (G0151) 
provided on September 15, 2021. 
 You asked the Plan to pay for the PT visit. You say that you stopped physical therapy because of the swelling 
in your knee. You say that you were told you could go to physical therapy on an outpatient basis. You say that 
you do not agree with this. You also say that you require additional physical therapy services. The Plan denied 
your request. The Plan says the home health visit was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 PT visit. Our reviewer says that the PT 
visit was not medically necessary. Our physician reviewer found the documentation does not support that you 
require in-home skilled rehabilitation services to provide treatment that is medically necessary. The reviewer 
also found that the documentation does not support that you are homebound. 
 
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 PT visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the physical therapy (PT) visit in your home (G0151) provided on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Oxycodone.  
 
Benefits for this drug 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 pay for the outpatient office visit provided on November 16, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you are not able to afford what is due and 
you were not informed that the provider was not in network. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 outpatient office visit provided on November 
16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS implantation for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. 
 
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. There remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. Our physician reviewer 
found that the enrollee's condition does not meet 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 does not 
have to pre-approve CardioMEMS implantation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing coded as 81295, 
81298, 81317, 81321, 81162, 81191 and 81401 provided March 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of the 
determination and coverage of the test at the in network benefit level. The Plan denied your request. The Plan 
says does not meet Medicare NCD/LCD criteria. Diagnosis code does not substantiate service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 comprehensive genomic profile testing coded as 81295, 81298, 81317, 
81321, 81162, 81191 and 81401 provided March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network (OON) specialist services 
provided from November 29, 2021, to December 8, 2021. 
 
You asked the Plan to waive the deductible for the OON specialist services. You say that the claims should be 
paid as in-network since you were referred by your doctor. The Plan denied your request. The Plan says the 
correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 out-of-network deductible which applies to certain items and 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 out-of-network deductible which applies to certain items and 
services. This cost sharing is a contractual obligation that had not been met at the time the OON specialist 
services were received from November 29, 2021, to December 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for out-of-network (OON) specialist 
services provided from November 29, 2021, to December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of heart monitor (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not had any syncopal episodes (have not passed out) and 
have not used an external heart monitor; therefore, they cannot authorize this request at this time. 
 
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 service. Our physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an implantable loop reader (ILR). In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of heart monitor (CPT code 33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 
10, 2021, to July 20, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical record received and available for review does not support the condition treated as 
consistent with a systemic infectious process. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee had abdominal pain, diarrhea, nausea who was admitted to the 
hospital with suspected pneumonia and WBC 13. She was found to have acute cholecystitis with . Septicemia 
or severe sepsis  is not sufficiently supported in the notes as there was no clear evidence found for a severe 
systemic infection leading to organ failure. The disorder of biliary tract with CC (445) would be more 
appropriate for this patient's admission. There was no clear indication that the SOFA score rose as baseline Cr 
was not provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 10, 2021, to July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided to the enrollee 
on November 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service was inappropriate for this procedure. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found this procedure has a indicator of 3. The guidelines state that usually thereafter, the physician is engaged in performing the procedure, and a nurse 
will monitor the patient. CPT 99153 has no physician work associated with it and is therefore a technical 
component only code (PC/TC indicator 3). When billed in a facility setting it is not payable to the physician but 
may be paid to the facility. Therefore, this procedure was reported incorrectly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99153) provided to the enrollee on November 2, 2021.