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

 
We decided that the Plan does not have to pay for physician pathology services (88360-26) billed for date of 
service May 3, 2021. 
 
You asked the Plan to pay for physician pathology services. You say that there is no history of this claim in the 
provider's database, so this should not be denied as a duplicate. The Plan denied your request. The Plan says 
this service has already been billed by another provider and paid. There is no documentation to support that the 
provider in this case performed the service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physician pathology services have 
been met. Specifically, there is insufficient documentation in the record/pathology note to show that this 
provider performed the services at issue. Therefore, we decided that the Plan does not have to pay for physician 
pathology services (88360-26) billed for date of service May 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided December 12, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that these emergency services were necessary. 
The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on December 12, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 May 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on December 20, 2021. 
 
You asked the Plan to pay for acupuncture. You say that the acupuncture was medically necessary. The Plan 
denied your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is 
not supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist.  
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on 
December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), single or multiple trigger point(s) (20553) 
provided on January 31, 2022. 
 
You asked the Plan to pay for injections. You say that you are requesting a review of the medical records and 
reprocess of the claim based on medical necessity. The Plan denied your request. The Plan says the requested 
injections and/or applications are considered not medically reasonable and necessary and do not meet Medicare 
criteria for any use outside of the National Coverage Determination (NCD). 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 
modifier have not been met. Therefore, we decided that the Plan does not have to pay for injection(s), single or 
multiple trigger point(s) (20553) provided on January 31, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says step-therapy rules for the requested drug have 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 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. 
The case file does not contain documentation of trial and failure of Orthovisc, Synvisc or Synvisc One. The 
documentation does not support that Orthovisc, Synvisc or Synvisc One would likely be less effective and/or 
would likely have adverse effects for you. 
 
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 treatment with Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for metabolic panel services (80053, 83036 and 85025) provided 
on March 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were reasonable and necessary. 
The Plan denied your request. The Plan says these services were billed with diagnosis code Z00.00 (encounter 
for general adult medical examination without abnormal findings) and the documentation provided indicates 
that these services were provided as a screening. These services are not covered by Medicare when provided 
for screening purposes. 
 
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. 
 
Based on the documentation provided, the test at issue in this appeal 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 metabolic panel services (80053, 83036 and 85025) provided on March 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BaroStim Neo System Implant. 
 
You asked the Plan to pre-approve the BaroStim Neo System Implant. You say that the requested BaroStim 
Neo System Implant is medically necessary. The Plan denied your request. The Plan says the requested 
BaroStim Neo System Implant is not medically 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 pre-approve the BaroStim Neo System Implant. Our 
reviewer says that the requested BaroStim Neo System Implant is not medically necessary. Our physician 
reviewer found Baroreflex stimulation devices have been considered potential alternative treatments for 
resistant hypertension and heart failure. The BaroStim Neo system is an electronic pulse generator implanted 
underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator 
delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid 
arteries. In August 2019 the FDA approved the system for use in patients with refractory heart failure who 
remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an 
ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of BaroStim Neo in patient management. As a result, at this 
time the BaroStim Neo system would not be considered medically reasonable and necessary in this enrollees 
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 BaroStim Neo System Implant have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the BaroStim Neo System Implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiogram recording provided on March 
30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for external electrocardiogram recording. You say that the provider was in-network, 
and the device was medically necessary.  The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 
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 
external electrocardiogram recording. We found no exception that would require the Plan to pay for the external electrocardiogram recording. Therefore, we decided that the Plan does not have to pay for the external 
electrocardiogram recording provided on March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that you fell and hurt your neck and back. You say that 
this doctor has helped very much, and you should not have to pay this bill. The Plan denied your request. The 
Plan says chiropractic coverage only extends to treatment by means of manual manipulation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving but still requires acute-care services before 
transitioning to a lower level of care. The enrollee continues to receive acute-care services and these have not 
been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not 
currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making (99204) provided March 17, 2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that routine eye exams are 
covered. The Plan denied your request. The Plan says the copayment was applied 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 outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye. 
 
You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the Vision 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 the office or other 
outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate 
history and/or examination and moderate level of medical decision making (99204) provided March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug injection (J3490) billed on February 18, 
2022. 
 
You asked the Plan to pay for the unclassified drug injection (J3490). The Plan denied your request. The Plan 
says the submitted medical records do not support the units billed. 
 
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 J3490 is drugs unclassified injection. 
 
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 unclassified drug injection (J3490). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the medical records document the syringe containing hydromorphone, and to use the contents of the 
syringe to refill the pump. In this case, 125 units are not supported; therefore, procedure code J3490 cannot be 
verified. 
 
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 unclassified drug injection (J3490) have not been met. Therefore, we 
decided that the Plan does not have to pay for the unclassified drug injection (J3490) billed on February 18, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that the requested Epogen is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Retacrit OR Procrit first. 
 
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 Epogen. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). 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 Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care items provided on August 20, 2021. 
 
You asked the Plan to pay for wound care items. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for wound care items provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth guard. 
 
You asked the Plan to pre-approve 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 oral appliances used to treat other dental conditions are 
non-covered. 
 
We looked at the file and Medicare rules. The requested item is a mouth guard for a diagnosis of jaw pain. This 
item is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a mouth 
guard.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued repetitive transcranial magnetic stimulation 
(rTMS) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says all other uses of transcranial magnetic stimulation are considered experimental and 
investigational as they are not supported by controlled clinical trials. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request is for maintenance therapy after the enrollee had a setback after a trip. This patient has 
occurred PHQ 9 of 21 in July, 2022 whereas his baseline PHQ 9 was found to be 9 in February, 2022. Utilizing 
the information from LCD (L33398) maintenance therapy, continuous therapy, rescue therapy and extended 
activity therapy is considered investigational and experimental and is therefore not considered reasonable or 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued repetitive transcranial magnetic stimulation (rTMS) for the enrollee.