Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis related group 
(DRG) 280 and secondary diagnosis code N17.0 for dates of service December 27, 2021, to December 29, 
2021.  
You asked the Plan to pay for inpatient hospital services. You say that you have provided medical records to 
support the services at issue. 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, N17.0, defined as Acute 
kidney failure with tubular necrosis. 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 
inpatient hospital services. Our reviewer says that the inpatient hospital services at issue do not meet criteria for 
payment. Our physician reviewer found that the available medical records do not support DRG 280 and 
secondary diagnosis code N17.0.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with DRG 280 and secondary diagnosis code N17.0 for dates of service 
December 27, 2021, to December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you moved to a different state where your plan 
would not cover you. You also say you called numerous times to make sure the Plan had been cancelled. You 
also say that if the Plan did not cancel the policy, then they should be responsible for the date of service. The 
Plan denied your request. The Plan says services must be provided in-network for coverage. The Plan also says 
that the denial will be upheld due to you being seen by an out-of-network provider without authorization. 
 
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 office visit provided on February 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says that IRF criteria was not 
met, and a lower level of care might be appropriate. Skilled nursing facility (SNF) care was offered. 
 
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 found to be medically reasonable and necessary for you. Our physician reviewer found 
clinical documentation shows that you have post-op complications and would be expected to require close 
medical monitoring on an inpatient basis during rehabilitation. Evaluating therapists (PT, OT) state that you 
would tolerate 3hrs of therapy per day and recommend intense therapy thus IRF criteria have been met and is 
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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for administration of a tetanus, diphtheria toxoids and acellular 
pertussis (Tdap) vaccine provided on February 9, 2022. 
 
You asked the Plan to pay for a Tdap vaccine. You say that the Plan contract indicates that vaccines are a 
covered benefit. The Plan denied your request. The Plan says rules for payment for immunizations have not 
been met. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for administration of a tetanus, diphtheria toxoids and 
acellular pertussis (Tdap) vaccine provided on February 9, 2022.  
 
 
 
 
 
 
  
 
Benefits for a Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 29, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (88305) provided on April 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the documentation 
received does not include records for the rendering provider. 
 
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. The submitted documentation does not show that the Plan requested medical 
records from the rendering provider. Therefore, we decided that the Plan has to pay for the lab services (88305) 
provided on April 11, 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 the home health services provided on May 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that you have a contract with the plan to be billed at 
a per-visit rate. The Plan denied your request. The Plan says rules for coverage 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 code. We looked at the file and the rules. The claim was billed with type of bill 323. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health services provided on May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you are asking for a reconsideration of 
this decision as this procedure has proven successful in reducing your upper back chronic nerve pain. The Plan 
denied your request. The Plan says the safety and efficacy of the Superion Interspinous spacer has not been 
studied in patients with lumbar spinal stenosis at more than two levels. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex interspinous spacer device (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 5, 2021, billed 
with codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301 and 
81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test has not been approved by 
the Food and Drug Administration (FDA) and this claim was not billed in accordance with Medicare rules. 
 
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 5, 2021, billed with codes 81191, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301 and 81311.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. You say that the enrollee requires this test 
to be done. You also say that it has been almost a year since the enrollee had any imaging done. The Plan 
denied your request. The Plan says the myocardial perfusion imaging requested does not meet the requirements 
for approval. 
 
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 a myocardial perfusion imaging. Our 
reviewer says that the requested myocardial perfusion imaging is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of coronary artery disease and 
previous percutaneous coronary intervention less than one year ago and has no cardiac symptoms. There is no 
documentation that the electrocardiogram shows an uninterpretable pattern. Our reviewer found that there is no 
evidence provided that would support the need for radionuclide stress testing. Our physician reviewer also 
found that there is insufficient documentation to support the medical necessity for the requested cardiac stress 
testing in this enrollees clinical management. 
 
 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 myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging (78452).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a GYN office visit provided on November 29, 2021. 
 
You asked the Plan to pay for a GYN office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that your Plan does not cover more than 1 routine GYN visit every 24 
months and you have reached the limit for this service. 
 
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. Specifically, the Plan has not provided us with documentation to support that 
you have exceeded the Plans routine GYN benefit. Therefore, we decided that the Plan has to pay for a GYN 
office visit provided on November 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that Durolane is what you have in stock. You also say 
that you do not have Orthovisc, Monovisc, or Synvisc. The Plan denied your request. The Plan says the 
provided information does not indicate that the enrollee has tried at least one of the alternative drugs. The Plan 
also says a reason why an exception should be made to the step therapy requirements was not provided. 
 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 Durolane. Our reviewer says that the 
enrollee does not meet coverage criteria for Durolane. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim for services 
rendered to the enrollee on December 14, 2021. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 office visit provided on December 14, 2021, by 
an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) test (0037U) provided February 15, 
2022. 
 
You asked the Plan to pay for the F1CDx test. You say that this test is a medically necessary covered benefit. 
The Plan denied your request. The Plan says that the next generation sequence testing (NGS) testing panel 
performed included testing for FANCC genes. Testing for these genes is not a Medicare benefit and is 
statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that the FoundationOne CDx test is covered when it 
is FDA approved for the enrollees diagnosis. 
 
We looked at the file and Medicare rules. In this case the laboratory test performed is considered an ADLT. The sample in this case was collected during a hospital outpatient counter. Therefore, the date-of-service was 
correctly reported as the date the test was performed, February 15, 2022. Additionally, documentation shows 
that the F1CDx test was performed for the enrollees diagnosis of cholangiocarcinoma. Cholangiocarcinoma is 
a covered indication for F1CDx. Based on this information, we decided that Medicare rules for coverage of the 
F1CDx test have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx 
(F1CDx) test (0037U) provided February 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest (71250). 
 
You asked the Plan to pre-approve a CT of the chest. You say that the requested CT scan is ordered as a short 
time follow up from the CT performed on May 2, 202. The Plan denied your request. The Plan says a repeat 
CT of the chest is not reasonable or medically necessary until 18 to 24 months after the initial CT of the chest. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT of the chest. Our reviewer says 
that a CT of the chest is not reasonable and necessary. Our physician reviewer found on the CT from October 
15, 2021, an 8-millimeter, non-calcified right lower lobe nodule was noted. A CT of the chest was then done on 
May 2, 2022, which showed the nodule had decreased in size, then measuring 5 millimeters in diameter. Our 
reviewer found that since the nodule had decreased in size since the October 15, 2021, study, a 12-month 
follow-up after the May 2, 2022, exam is indicated, rather than a 6-month follow-up as requested. 
 
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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the chest (71250).