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

 
We decided that the Plan does not have to pay for lab services (81227, 81230, 81231, 81232, 81306, 81328, 
81355, 81335, 00331U, 0032U, 0033U) provided February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were submitted for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81227, 81230, 81231, 81232, 81306, 81328, 81355, 
81335, 00331U, 0032U, 0033U) provided February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a high frequency chest wall oscillation device is 
covered for the indications established in the applicable LCD. 
 
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 device. Our reviewer says that the 
requested high frequency chest wall oscillation device is not medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has severe chronic obstructive pulmonary disease (COPD). 
There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. There is inadequate evidence 
that this treatment is of benefit in COPD. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a high frequency chest wall oscillation device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 25, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 laboratory services provided on March 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided on March 26, 2022. 
 
You asked the Plan to pay for home infusion therapy services. The Plan denied your request. The Plan says the 
Plan does not cover service line S9328 when performed 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 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 home infusion therapy services provided on March 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has stabilized medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate.   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81227, 81230, 81231, 81232, 81291, 81306, 
81355, 0031U, 0032U, 0033U) provided February 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. 
 
We looked at the file and Medicare rules. Multiple codes were billed for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81227, 81230, 81231, 81232, 81291, 81306, 
81355, 0031U, 0032U, 0033U) provided February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
January 27, 2022. 
 
You asked the Plan to pay for critical care. You say that this service was medically necessary and was reported 
correctly. The Plan denied your request. The Plan says this service is not supported in the medical records 
provided. 
 
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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no critical care note 
in the record with the time spent providing this service. Without this information, a time-based code such as 
99291 cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour 
(99291) billed for date of service January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting admission into an inpatient 
rehabilitation for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee h a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detection test by immunoassay technique for COVID-19 
(87426) and other special service, procedure, or report (99199) purchased on May 13, 2022. 
 
You asked the Plan to pay for the detection test by immunoassay technique for COVID-19 and other special 
service, procedure, or report. You say that you needed the COVID-19 test in order to return to the United States 
from another country. The Plan denied your request. The Plan says COVID-19 testing for non-diagnostic 
testing for screening purposes is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
 
 
 
 We looked at the file and Medicare rules. This testing was required by a third party for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the detection test by immunoassay 
technique for COVID-19 (87426) and other special service, procedure, or report (99199) purchased on May 13, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
April 1, 2022. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that the enrollee was diagnosed 
with dementia and had to be transported with assistance to a nursing home for permanent care. The Plan denied 
your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that miles beyond the closest available facility cannot 
be billed to Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-covered ambulance mileage have not been met. Therefore, we decided that the Plan does 
not have to pay for the non-covered ambulance mileage (A0888) provided on April 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says there is no documentation submitted from the requesting 
physician to show that the enrollee has had either a failure or a contraindication to the use of the preferred 
medication. 
 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 Eylea. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Avastin or 
medical record documentation of baseline visual acuity of 20/50 or worse before they will approve the 
requested drug, Eylea. There is no indication that the patient has tried and failed the required drug. The only 
provided medical record documents the enrollee's visual acuity as 20/20 -3 in the right eye and 20/30 -1 in the 
left eye. Based on the medical records provided and the Medicare-approved major drug compendia there is no 
indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64635). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee does not have radicular symptoms 
therefore he Is not a surgical candidate at this point. The Plan denied your request. The Plan says the criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that if there is an extended time, two years or more, since 
the last RFA then diagnostic procedures must be repeated. 
 
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 injection. Our reviewer says that the 
requested radio frequency ablation (RFA) is not medically necessary. Our physician reviewer found the 
provided documentation indicates that the prior radio frequency ablation (RFA) occurred more than 2 years 
ago. As a result, the diagnostic medial branch blocks (MBBs) must be repeated. Therefore, the RFA would be 
not medically reasonable or necessary at this time. 
 
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 pre-approve destruction by neurolytic agent (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system. 
 
You asked the Plan to pre-approve a Volara system. You say that the Volara system manages the enrollee's 
ongoing pulmonary exacerbations at home and greatly increase the enrollee's bronchial drainage. The Plan 
denied your request. The Plan says the Volara System is a 3-in-1 combined therapy device that includes an IPV 
device that is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Specifically, the Volara system, for use in the home, includes an IPV 
device that is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules 
for coverage of a Volara system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Volara system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 10, 2021 billed 
with codes 81479, 81235, 81275, 81401, and 81210. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding. 
 
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 
September 10, 2021 billed with codes 81479, 81235, 81275, 81401, and 81210.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a triamcinolone acetonide injection 
provided on April 19, 2022. 
 
You asked the Plan to waive the copayment for a triamcinolone acetonide injection. You say that you have 
already paid so much for this issue, you want this one waived. You do not feel you were in an observation 
room at all. The Plan denied your request. The Plan says the copayment that was applied was 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 $210 
copayment for outpatient hospital visit.  
 
 
 
 
 
 You have been asked to pay a $210 copayment for a triamcinolone acetonide injection. a triamcinolone 
acetonide injection falls within The Outpatient Surgery, Including Services Provided at Hospital Facilities and 
Ambulatory Surgical Centers 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 a 
triamcinolone acetonide injection provided on April 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 
10, 2022, to April 8, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition did 
not require daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from March 10, 2022, to April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyrvaya Sol. 
 
You asked the Plan to pre-approve Tyrvaya Sol. You say that the enrollee has tried and failed other over-the-
counter prescription medications. You say that the records provided support the need for the requested drug. 
The Plan denied your request. The Plan says this self-administered drug is covered under a pharmacy benefit, 
which is not administered under this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tyrvaya Sol.  
 Benefits for Tyrvaya Sol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.