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

 
We decided that the Plan does not have to pre-approve Feraheme for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the preferred drugs do not require authorization. 
 
 
 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Ferrlecit, Infed, Sodium Ferric Gluconate or Venofer before they will approve the requested drug. In this 
case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that 
the plans required drugs 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the BinaxNOW COVID test purchased on February 9, 
2022. 
 
You asked the Plan to reimburse for the BinaxNOW COVID test. You say that you are requesting 
reimbursement of services rendered. The Plan denied your request. The Plan says no order was provided by 
your physician. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Since records do not indicate medical necessity and no order was 
provided by your physician, your appeal for reimbursement of $23.99 for the BinaxNOW COVID test 
purchased at the pharmacy has been denied. Therefore, we decided that the Plan does not have to reimburse for 
the BinaxNOW COVID test purchased on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging (code 78452-26) you 
received on August 12, 2021. 
 
You asked the Plan to pay for the myocardial perfusion imaging. You say that this is the only insurance you 
have.  You also said that you believe this claim was denied because the provider didn't file the claim in time. 
The Plan denied your request. The Plan says it cannot pay anything on this claim until the claim is processed by 
your primary insurer. 
 
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 contacted 
this provider and directed them to bill your primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the myocardial perfusion imaging until the primary insurer has denied the claim for these 
services. Please note- if you believe that you were not a member of any other insurance on the date of service, 
you will need to address that issue with the primary insurer listed on your account directly. Therefore, we 
decided that the Plan does not have to pay for the myocardial perfusion imaging (code 78452-26) you received 
on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing panel provided on 
October 15, 2021. 
 
You asked the Plan to pay for the next generation sequence testing panel. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel provided included testing for the FANCC gene. This means the entire panel is non-covered. Based on this 
information, we decided that Medicare rules for coverage of the next generation sequence testing panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the next generation sequence testing 
panel provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment; spinal, 1-2 regions. 
 
You asked the Plan to pre-approve chiropractic manipulative treatment; spinal, 1-2 regions. You say that 
chiropractic manipulative treatment; spinal, 1-2 regions is medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare coverage criteria. 
 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.  
 
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 chiropractic manipulative treatment; 
spinal, 1-2 regions Our reviewer says that chiropractic manipulative treatment; spinal, 1-2 regions are not 
medically necessary. Our physician reviewer found that the clinical documentation does not support that a 
physical examination of the back, musculoskeletal system, and nervous system have been done. There is no 
documentation of subluxation demonstrated by X-ray or physical examination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment; spinal, 1-2 regions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment; spinal, 
1-2 regions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM). 
 
You asked the Plan to pre-approve implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM). You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the requested services are 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 implantation of a cardiac contractility 
modulation system in the form of the Optimizer Smart device (CCM). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has left ventricular dysfunction with continued symptoms, despite medical treatment, 
thought to reflect congestive heart failure. Several randomized clinical trials of CCM versus control have also 
been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing 
meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies 
led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as 
well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, 
the CCM system is not found to be medically necessary for 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 implantation of a cardiac contractility modulation system in the form of the 
Optimizer Smart device (CCM) have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation of a cardiac contractility modulation system in the form of the Optimizer Smart device 
(CCM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device 
coded E0730, the needle electromyography services coded 95886, and the nerve conduction studies coded 
95912 provided on March 15, 2021. 
 
You asked the Plan to pay for the transcutaneous electrical nerve stimulation (tens) device, the needle 
electromyography services, and the nerve conduction studies. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. TENS is only covered for enrollees who are 
enrolled in a clinical study. 
 
The documentation does not support that the enrollee was enrolled in a clinical study. 
We also find that CPT codes 95886 and 95912 are not supported in the medical record. Specifically, the 
technical report did not include documentation of a complete needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; 
for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. Code 95886 is 
an add-on code. Since the primary procedure is denied, so this the add-on code. Based on this information, we 
decided that Medicare rules for coverage of the transcutaneous electrical nerve stimulation (tens) device, the 
needle electromyography services, and the nerve conduction studies have not been met. Therefore, we decided 
that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device coded 
E0730, the needle electromyography services coded 95886, and the nerve conduction studies coded 95912 
provided on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of Orthovisc or Supartz FX 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided on December 
13, 2021. 
 
You asked the Plan to pay for a total electric hospital bed. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the item at issue is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
(E0265) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT code 99291) and critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (CPT code 99292) 
provided on December 3, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes and code 99292 is critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes. 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. CPT code 99291 (1 Unit) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was 
performed on the billed date of service. The documentation does not include the time spent providing this 
service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information.  
 
CPT code 99292 (2 Units) remains not supported. This CPT is an add-on type code that requires a primary 
code. Since the primary code is not supported, this code cannot be separately reimbursed. In addition, the 
documentation submitted did not support a critical care visit of an additional 30 minutes of critical care time in 
addition to the first 30-74 minutes of a critical care evaluation and management service (CPT code 99291) for 
this date of service. The documentation does not include the time spent providing this service. It is noted that 
multiple attempts were made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured 
patient; first 30-74 minutes (CPT code 99291) and critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (CPT code 99292) provided on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prostate Cancer Gene Expression provided on September 9, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Prostate Cancer Gene Expression. You say that you would like to appeal the 
denial of the claim and that authorization was submitted plus approved for the testing. The Plan denied your 
request. The Plan says authorization was not submitted for the testing and authorization is required prior to an 
out-of-network visit. 
 
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 Prostate Cancer Gene Expression provided on 
September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services received from September 2, 2021 
to October 21, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services received 
from September 2, 2021 to October 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90832, 90834) provided 
July 7, 2021 to September 30, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC) are not 
eligible for Medicare payment. 
 
We looked at the file and Medicare rules. This service was provided by a provider that is not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental 
health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services (90832, 90834) provided July 7, 2021 to September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient 
hospital care does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria inpatient hospital care is not medically 
necessary. Our physician reviewer found an MRI revealing advanced degenerative disc disease at C5-6 
and C6-7 with foraminal stenosis at C5-6 and C6-7 on the right. Her symptoms have persisted despite several 
months of medication, therapy, ice, heat, massage, and ultrasound/E-stim. She is to undergo a cervical fusion. 
The enrollee is medically stable and there is no specific clinical rationale for inpatient level of care services for 
the elective outpatient procedure. The record does not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
does not have to pre-approve acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to the requested 
provider's office. Your primary care doctor referred you to this provider and if you are not approved for the 
additional miles of transportation, you will have to cancel your appointment. The Plan denied your request. The 
Plan says you are requesting an additional 6.6 miles for a total of 56.6 miles and your benefit only allows 50 
miles. The Plan also says you have exceeded your benefit limit. 
 
 
 
 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 up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional minutes of acupuncture (97811) provided on June 
29 to July 6, 2021. 
 
You asked the Plan to pay for additional acupuncture. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
additional acupuncture is an add-on code. The appropriateness of the billed primary procedure code cannot be 
verified from the available medical records. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for additional minutes of acupuncture (97811) provided on June 29 to July 6, 2021.