Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional catheter supplies (A4217, A4357). 
 
You asked the Plan to pre-approve the additional catheter supplies. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says these items are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that when syringes, trays, sterile saline, or water are 
used for routine irrigation, they will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The items are for routine irrigation and are non-covered. Based on 
this information, we decided that Medicare rules for coverage of the additional catheter supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve additional catheter supplies (A4217, 
A4357).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 You asked the Plan to pre-approve Genvisc 850. 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. 
 
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 Genvisc 850. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plan's additional required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Genvisc 850 is not approved, as step criteria have 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 Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve histotripsy of malignant hepatocellular tissue (0686T). 
 
You asked the Plan to pre-approve histotripsy. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve histotripsy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical application of histotripsy has made significant progress in the treatment of liver 
tumors, benign prostatic hyperplasia, and aortic valve calcification stenosis. Phase I clinical trials have 
demonstrated the safety and efficacy of histotripsy in the treatment of these diseases. More research is needed to evaluate and optimize its efficacy and safety and to fully explore its mechanism of action, pathological and 
immunological effects, and the short-term and long-term reactions of the body after treatment. The conclusions 
is that histotripsy has broad application prospects in ablation therapy and will benefit patients after more 
clinical trials are conducted in the future. The review has determined that the items/services at issue in this case 
are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of histotripsy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve histotripsy of malignant hepatocellular tissue (0686T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastroenterology visit (99214) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the gastroenterology visit. You say that this service is medically necessary. 
The Plan denied your request. The Plan says there are 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
gastroenterology visit (99214) to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99282, J3490) provided on 
November 7, 2022. 
 
You asked the Plan to pay for the emergency room visit. You say that you are being billed an addition $8.04 for 
the emergency room visit that should be covered. The Plan denied your request. The Plan says the plan has 
already paid $3.92 towards the amount above the $110 copayment. Documentation does not support additional 
payment. 
 
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 $110 for 
Emergency Care.  
 
The plan has already covered the $3.92 in excess of the $110 copayment. The receipt provided is illegible and it is not clear if an additional amount is being billed. 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 pay for an emergency 
room visit (99282, J3490) provided on November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows spinal stenosis. The cause of back pain 
is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 11, 2022, 
to October 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 11, 2022, to 
October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing (94726, 94060, 94729, 94618) 
provided on September 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic testing. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services are not covered when provided by a non-participating 
provider. 
 
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 diagnostic testing (94726, 94060, 94729, 
94618) provided on September 1, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the records do not show that HBO therapy will be used as an adjunct to conventional wound 
treatment. The enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision (99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 7, 2022, billed with 
codes 87529, 87556, 87491, and 87481. 
 
You asked the Plan to pay for the genetic testing billed. You say that medical records were submitted. The Plan 
denied your request. The Plan says the proprietary lab is requesting coverage of the comprehensive panel by 
stacking codes. 
 
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 
July 7, 2022, billed with codes 87529, 87556, 87491, and 87481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation device. You say that this device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (E0483).
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 enrollee has had a change in progress 
and an LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee is 
currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 3, 2022. 
 
You asked the Plan to pay for the office visit. You say that the treatments are very helpful in getting you in 
good shape with alignments. You say that you are questioning why this was not paid. The Plan denied your 
request. The Plan says Medicare will only cover manual manipulation of the spine to correct subluxation. 
 
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 October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services rendered from July 12, 2018, 
to August 17, 2018. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee has not acted upon their delusions, and there are no recent medication 
changes. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 that the 
progress notes do not indicate that the enrollee had been aggressive with peers or staff on the unit or had had 
any recent attempt to harm himself as of the last covered date. There was no indication in the available medical 
records that the enrollees psychiatric symptoms could not be managed on a less restrictive basis. The enrollee 
was noted to have confusion at his baseline mental status. The enrollee was not exhibiting any other significant 
symptoms. The enrollee had no acute psychiatric issues that would require continued inpatient care. The 
enrollee has chronic symptoms. The available medical records do not support that inpatient care would have 
changed these symptoms or the enrollee's current condition. The enrollee is chronically impaired due to 
Schizophrenia and the continued inpatient hospital stay was not expected to improve the enrollee's condition in 
a reasonable period of time. The continued inpatient hospital stay beyond 07/22/2018 was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient mental health services rendered from July 12, 2018, to August 17, 2018.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the laser assisted cataract surgery provided on October 31, 2022, and 
November 7, 2022. 
 
You asked the Plan to pay for the laser assisted cataract surgery. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the laser assisted cataract surgery based on Medicare criteria. CMS has provided the 
following guidance in response to a press release from an ophthalmology practice and the use of bladeless, 
computer-controlled laser surgery for cataract removal that is being charged to the enrollee. Medicare coverage 
and payment for cataract surgery is the same irrespective of whether the surgery is performed using 
conventional surgical techniques or a bladeless, computer-controlled laser. Under either method, Medicare will 
cover and pay for the cataract removal and insertion of a conventional intraocular lens. Services that are part of 
cataract surgery with a conventional lens, including but not necessarily limited to the incision by whatever method, capsulotomy by whatever method, and lens fragmentation by whatever method, may not be charged to 
the enrollee. 
 
We looked at the file and Medicare rules. The Plan did not provide any claims for us to be able to review and to 
verify what services have and have not been paid for in relation to the cataract surgeries. Without these claims, 
we are unable to determine an amount that may or may not be owed. Therefore, we decided that the Plan has to 
pay for the laser assisted cataract surgery provided on October 31, 2022, and November 7, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 22, 2022, to 
February 20, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 22, 2022. The NOA was not received by the Plan until March 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 22, 2022, to February 20, 2022.