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

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI of the cervical and thoracic spine is not established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a nerve test provided on September 15, 
2021. 
 
You asked the Plan to reduce the copayment for a nerve test. You say that you should only have a $30 copay, 
not $35. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a nerve test. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 reduce the copayment for a nerve test provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 2 reader. 
 
You asked the Plan to pre-approve a Freestyle libre 2 reader. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle libre 2 reader.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Pegfilgrastim injection provided to the enrollee on July 18, 
2022. 
 
You asked the Plan to pay for the injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says services that are not medically necessary are not covered under the Evidence of 
Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found that no recent labs 
are provided for use in the recent clinical notes. There is no clear indication noted for this injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a Pegfilgrastim injection provided to the enrollee on July 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service September 
23, 2022. 
 You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 is a column II code to column I code 93976. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, the Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
76700 billed for date of service September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home visual field monitoring with the ForeseeHome 
device (0379T). 
 
You asked the Plan to pre-approve the ForeseeHome device. You say that this service is approved by the Food 
and Drug Administration (FDA) and has been covered by Medicare since 2015. You also say that this service is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested service 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 ForeseeHome device. Our reviewer 
says that the requested the ForeseeHome device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested ForeseeHome device is considered experimental. Therefore, 
the reviewer found that the ForeseeHome device is 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 the ForeseeHome device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home visual field monitoring with the ForeseeHome device (0379T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for the home health services. You say that the date was erroneously keyed in. 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 and the 
NOA were not billed with a 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 July 1, 2022, to July 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique (87640) provided on October 4, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the ordering physician ordered the lab panel 
because it was medically necessary based on the enrollee's current sign and systems. You are hoping the claim 
will be reviewed for medical necessity and preprocessed for payment. The Plan denied your request. The Plan 
says the request does not meet Medicare rules as reasonable and 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 pay for laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented for an evaluation for dysuria and urinary frequency for 3 days with lower 
abdominal pain, low back pain, chills, and nausea. Urinalysis was outside normal limits. A UTI-Pro Panel was 
ordered for diagnoses of dysuria and acute cystitis with hematuria. Per the literature, the PCR urine test utilizes 
a technologically advanced process to "copy" a portion of DNA from the enrollee's urine sample in order to 
identify the precise pathogen causing their UTI, which antibiotics may be most effective to treat their UTI, and 
to which antibiotics their bacteria may be resistant. The standard of care for evaluation of urinary tract infection 
includes a urinalysis, followed by a urine culture and susceptibility studies. In addition, there is lack of support 
for the clinical utility of large multiplex PCR urinary tract infection panel tests. The review has determined that 
the services at issue in this case were 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 laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for an infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, 
amplified probe technique (87640) provided on October 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 2, 2022, to March 
3, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing with proof of timely filing of 
the Notice of Admission. The Plan denied your request. The Plan says the claim does not have the correct 
admission date of January 3, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that for beneficiaries receiving home health services 
in 2021 that will continue in 2022, the home health agency should use an artificial admission date 
corresponding to the From date of the first period of continuing care in 2022.  
 
We looked at the file and Medicare rules. This claim was not billed with an artificial admission date 
corresponding to the From date of the first period of continuing care in 2022. Based on this information, we 
decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the 
Plan does not have to pay for home health care provided from February 2, 2022, to March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Lumbar-sacral orthosis (L0650), provided on August 25, 
2022. 
 
You asked the Plan to pay for the Lumbar-sacral orthosis. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the member was contacted by telephone for this item and did not need 
or receive the item. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the Lumbar-sacral 
orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the Lumbar-sacral 
orthosis (L0650), provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that the enrollee has a treatment history with the 
OON provider; therefore, the requested office visit should be approved. The Plan denied your request. The Plan 
says the service can be provided by an in-network 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 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 provider at issue in this case is not a network provider with the Plan. 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 specialist visit. Our physician reviewer found it is not medically necessary 
to continue seeing the OON provider. The health plan documents that they have two providers within the same 
specialty within a reasonable distance from the enrollee's home. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of specialist visit have not been met.  
 
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 specialist visit. Therefore, we decided that the Plan 
does not have to pre-approve specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery and a specialist office 
visit provided on January 19, 2022, to April 11, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery and a specialist office visit. You say that you 
disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment for outpatient surgery/Medicare-covered surgery and a $40 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a $325 copayment for outpatient surgery and a $40 copayment for a specialist 
office visit. The total amount you are being asked $365 ($325 + $40 = $365). This item/service falls within the outpatient surgery/Medicare-covered surgery and physician/practitioner services/specialist 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 outpatient surgery and a specialist office visit provided on 
January 19, 2022, to April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided on May 2, 2022, to May 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient stay. You say that we depend upon the facility staff to verify 
eligibility and to obtain authorization from the patients insurance. The Plan denied your request. The Plan says 
there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility. 
 
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 inpatient stay provided on May 2, 2022, to May 
11, 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 advanced care planning (99497 x 2) and subsequent 
nursing facility care (99309) provided from May 9, 2022, to May 11, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the physician services. You say that the provider depends on the facility staff to 
verify eligibility and to obtain the proper authorization. The Plan denied your request. The Plan says prior 
authorization was not 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 provider in this case is not a network provider with the Plan. 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 advanced care planning (99497 x 2) and subsequent nursing 
facility care (99309) provided from May 9, 2022, to May 11, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for 
the requested device. The Plan denied your request. The Plan says the requested home ventilator would be set 
in pressure support (PS) with safety tidal volume mode that could be delivered by bi-level positive airway 
pressure (BiPAP) and is therefore not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee has severe chronic obstructive pulmonary disease (COPD) and was recently 
hospitalized with an exacerbation.  Arterial blood gasses (ABGs) were consistent with acute on chronic hypercarbic respiratory failure.  Although there is no ABG done while stable, it is likely this enrollee has 
chronic carbon dioxide (CO2) retention and may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep as an outpatient.  This has not been tried and documented to fail as an 
outpatient.  Failure to immediately normalize the PaCO2 during acute illness does not constitute failure of 
BiPAP as an outpatient.  Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on 
December 15, 2021.  
You asked the Plan to pay for the lab services. You say that the records prove medical necessity. The Plan 
denied your request. The Plan says the services are not covered by Medicare. 
 
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. 
 
We looked at the file and the rules. The testing at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does 
not have to pay for the hereditary cardiovascular gene panel provided on December 15, 2021.