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

 
We decided that the Plan does not have to pre-approve injectable allogeneic nucleus pulposus. 
 
You asked the Plan to pre-approve injectable allogeneic nucleus pulposus. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 injectable allogeneic nucleus pulposus. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found injectable allogeneic nucleus pulposus is purely experimental. More 
research is needed to show safety and efficacy before coverage can be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injectable allogeneic nucleus pulposus have not been met. Therefore, we 
decided that the Plan does not have to pre-approve injectable allogeneic nucleus pulposus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist appointment and a diagnostic 
test provided on January 07, 2022, January 14, 2022, and January 21, 2022. 
 
You asked the Plan to waive the copayments for a specialist appointment and a diagnostic test. You say that 
you feel you are being charged too much. The Plan denied your request. The Plan says the copayments applied 
were correct. 
 
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 $25 
copayment for other outpatient diagnostic tests and a $15 copayment for a consultation, diagnosis, and 
treatment by a specialist.  
 
You have been asked to pay a total of $120 for three specialist appointments with a diagnostic test ($15 for a 
specialist visit + $25 for a diagnostic test = $40 / $40 x 3 visits = $120).  
A specialist appointment falls within the Consultation, Diagnosis, and Treatment by a Specialist benefit 
category, and a diagnostic test falls within the Other Outpatient Diagnostic Tests 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 copayments for a specialist appointment and a diagnostic test provided on 
January 07, 2022, January 14, 2022, and January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation for future doctor appointments. The Plan denied your request. The Plan says you have exhausted 
the maximum benefit of 24 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve a home health aide. 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you do not have documented 
skilled nursing needs or skilled therapy needs. Your needs appear to be custodial. Your needs appear to be 
chronic and long-term, rather than intermittent and temporary.  As such, home health services, including 
associated home health aide services, are not shown to be medically necessary, reasonable or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home health aide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home health aide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and associated accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that this 
power wheelchair is medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says the criteria for a group 3 power wheelchair with multiple power options have not been met. The enrollee 
would qualify for a group 3 power wheelchair with no power option. 
 
The Plan follows Medicare rules. Medicare rules say that the group 3 power wheelchair with multiple power 
options is subject to the criteria listed 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested group 3 power wheelchair with multiple power 
options is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the 
enrollee has a neurological condition, progressive supranuclear palsy and has progressively lost the ability to 
ambulate safely. They do not use a ventilator or a respiratory assist device. In addition, the enrollee is able to 
weight shift and does not use intermittent catheterization. Therefore, the criteria for a power tilt and recline 
seating system have not been met. Subsequently, the criteria for the group 3 power wheelchair with multiple 
power options have also not been 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 a group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options and associated accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81206, 81210, 81235, 81272, 81275, 81301, 81311, 81292, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing which 
should be covered. The Plan denied your request. The Plan says this was not billed correctly with a single panel 
code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 8, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81301, 81311, 81292, and 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87808) provided on May 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-authorized or emergent. There 
were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (87808) provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services coded 81455 provided on 
October 26, 2021. 
 
You asked the Plan to pay for the genetic testing services coded 81455. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says this testing was correctly 
denied as services that are unlikely to impact therapeutic decision-making. 
 
The Plan must follow Medicare rules. Medicare rules say that before April 1, 2022, Current Procedural 
Terminology (CPT) code 81455 was listed as a group 3 tier 1 non-covered code. Genetic testing procedures 
submitted with this code were classified as unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services coded 81455 have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services coded 81455 
provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the eyewear allowance of $100 for eyewear provided on  
November 19, 2021. 
 
You asked the Plan to pay the eyewear allowance of $100 for the eyewear. The Plan denied your request. The 
Plan says that the claim processed with the correct vision benefit allowance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan did not pay the maximum eyewear 
benefit allowance of $100. Therefore, we decided that the Plan has to pay the eyewear allowance of $100 for 
eyewear provided on November 19, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequencing (NGS) panel provided to the 
enrollee on March 22, 2022. 
 
You asked the Plan to pay for the NGS panel. You say that you would like the claim for this testing 
reprocessed for medical necessity. The Plan denied your request. The Plan says no clinical information was 
submitted to demonstrate complete blood cell (CBC) count results or to demonstrate how the testing will have 
an impact on care. 
 
The Plan follows Medicare rules. Medicare rules say that the NGS panel is subject to the criteria listed 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 pay for the NGS panel. Our reviewer says that the 
ordered testing was not medically reasonable and necessary according to Medicare rules. Our physician 
reviewer found that the review indicates that the 92-year-old enrollee has anemia, mild neutropenia and 
thrombocytopenia. The requested NGS panel of 51+ genes was performed to rule out leukemia, lymphoma and 
myelodysplastic syndrome. There was no clinical information submitted to demonstrate the CBC results or to 
demonstrate how the testing will have an impact on the enrollee's care. The review has determined that the 
enrollee does not meet the criteria for this testing. 
 
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 NGS panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the next generation sequencing (NGS) panel provided to the enrollee on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on September 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON podiatry care. You say that the enrollee indicated that she was covered 
by Original Medicare. Because of this misinformation, authorization could not be requested. The Plan denied 
your request. The Plan says providers are responsible for obtaining valid insurance information before 
rendering services. This visit was not emergent, and no authorization was obtained for OON care. 
 
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 podiatry services provided on September 9, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second magnetic resonance imaging (MRI) interpretation 
provided on March 14, 2022, billed with codes 74183-26-76 and 76376-26. 
 
You asked the Plan to pay for the second interpretation of the MRI scan. You say that the records show that 
there are two reports. This means both should be paid. The Plan denied your request. The Plan says there is no 
evidence that two services were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that MUEs limit the number of units for certain 
services. Though some MUEs can be overridden, supporting documentation must be provided.  
 
We looked at the file and Medicare rules. The records show that the same radiologist signed two reports 
interpreting the same image. Modifier -76 means that the service was repeated by the same physician on the same date of service. While this is appropriately used, there is no indication that two separate interpretations 
were actually performed as the report for both is identical. There is also no rationale for the radiologist to 
review the imaging once more after the initial interpretation when there were no changes to the report. 
 
Based on this information, we decided that Medicare rules for coverage of the second interpretation of the MRI 
scan have not been met. Therefore, we decided that the Plan does not have to pay for the second magnetic 
resonance imaging (MRI) interpretation provided on March 14, 2022, billed with codes 74183-26-76 and 
76376-26.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has heterogenously dense 
tissue which somewhat limits the utility of screening mammography; however, her calculated Tyler-Cuzick 
risk is 0.9 percent, which places her in the less than 15 percent lifetime risk category. She has had no genetic 
testing to indicate BRCA-1 or -2 genetic predisposition for breast cancer. She had a negative breast MRI on 
March 19, 2021. The MRI would be considered screening in nature and not medically necessary over the 
standard screening mammography. 
 
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 magnetic resonance imaging (MRI) of the breast.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional speech therapy visits. 
 
You asked the Plan to pre-approve 36 additional speech therapy visits. You say that additional speech therapy 
is medically necessary for your condition. The Plan denied your request. The Plan says the requested speech 
therapy services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 36 additional speech therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy generally is not 
accepted as specific and effective therapy for your condition beyond what was approved by the Plan. The 
patient has had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. You are independent in memory compensation strategies and further skilled therapy 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 36 additional speech therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 36 additional speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve routine transportation for a total of 51.44 miles. 
 
You asked the Plan to approve these services. You say that you need transportation to an upcoming dental 
appointment. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. The request is for a one-way trip of 51.44 miles, which exceeds the 50 mile limit. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to approve 
routine transportation for a total of 51.44 miles.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation, stretcher van transport. 
 
You asked the Plan to pre-approve non-emergency transportation, stretcher van transport. You say that you are 
bedridden and need a stretcher to travel and without seeing your provider your health will decline and get 
worse. The Plan denied your request. The Plan says he requested service is not covered by Medicare or the 
health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for stretcher van transport 
services. 
 
The services you have asked the Plan to pay for are stretcher van transport services. Therefore, we decided that 
the Plan does not have to pre-approve non-emergency transportation, stretcher van transport.