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

 
We decided that the Plan has to pay for diagnostic radiology provided on January 28, 2022.  
 
You asked the Plan to pay for diagnostic radiology. You say that the services were medically necessary, and 
also authorized. You are appealing with supporting records. The Plan denied your request. The Plan says that 
the enrollee must receive care from a network provider 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for diagnostic radiology by a contract provider. The file does not show that the Plan 
provided notice that diagnostic radiology would not be covered. Under Medicare rules, this means diagnostic 
radiology is considered approved by the Plan. Therefore, we decided that the Plan has to pay for diagnostic 
radiology provided on January 28, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on March 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this is not considered balance billing since the enrollee 
is in fact responsible after insurance denies a claim. The Plan denied your request. The Plan says claim lines 
with the GY modifier are automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A0425 and A0426 are not supported in the medical record. As these codes were billed 
with the GY modifier, they cannot be covered. 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 
ambulance services provided to the enrollee on March 18, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that Euflexxa is only approved for osteoarthritis of the knee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 pre-approve Euflexxa. Our reviewer says that the 
enrollee meets criteria for the requested use of Euflexxa. Our physician reviewer found the enrollee has a 
diagnosis of osteoarthritis of both knees. Use of Euflexxa is Food & Drug Administration (FDA) approved for 
this diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve 
use of Euflexxa.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discectomy, anterior, with decompression of spinal cord 
and/or nerve root(s), including osteophytectomy (63076, 63075) provided February 9, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that you do not disagree that the claim was 
overpaid, however, the requested amount is believed to be incorrect. The Plan denied your request. The Plan 
says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 3, 2021, and on May 6, 2021. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for the surgical procedure have 
not been met. Therefore, we decided that the Plan does not have to pay for the discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy (63076, 63075) provided 
February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000 x 2) provided on July 20, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Additionally, the rules say that with the exception of the situations described above, orthopedic 
footwear billed using code L3000 will be denied as non-covered. Therefore, we decided that the Plan does not 
have to pay for the foot orthotics (L3000 x 2) provided on July 20, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrent computed 
tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET-CT scan. Our reviewer says that 
the requested service is medically reasonable and necessary in this case. Our physician reviewer found that a 
comparison to the PET-CT scan of August 3, 2022, would be most useful in order to assess the metabolic 
activity of the nodes. If such activity has increased, even if size is unchanged, metastatic disease would be 
possible. The enrollee has had findings on the same side as the original tumor and careful caution concerning 
possible tumor recurrence or metastasis is necessary to optimize treatment in the event the tumor has returned. 
 
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 PET-CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET-CT scan (78815).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve thermal facet joint RFA. 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 an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 thermal facet joint RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires 2 sets of 
diagnostic MBBs which produce at least 80% pain relief. Only one set has been submitted. Therefore, the 
request is deemed 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 thermal facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal facet joint radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 2, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lokelma oral suspension. 
 
You asked the Plan to pre-approve Lokelma. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Lokelma 
oral suspension.  
 Benefits for Lokelma 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 use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this needs to be used for treatment of chronic 
obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says a ventilator is not covered 
by Medicare for the requested purpose and the enrollee's needs can be met by a bilevel positive airway pressure 
(BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected (December 14, 2021). 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 (81479) provided on January 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. 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 Entyvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug. The review has determined that the plans required drug would not likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the botox injections provided on July 19, 2022. We 
also decided that the Plan does not have to reduce the copayment for a specialist office visit provided on July 
19, 2022. 
 You asked the Plan to reduce the cost share for an office visit and injections. You say that you have never paid 
more than a $15 copayment for your botox injections. The Plan says that 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. The Plan contract also says that enrollees must pay a $32 
copayment for a specialists office visit. 
 
We decided that the Plan has to reduce the coinsurance for botox injections provided on July 19, 2022. 
 
The Plan says you must pay $92.85 a botox injection. You have also been asked to pay $30.95 for a second 
botox injection. Based on the Plan contract, however, you cannot be asked to pay more than 20% coinsurance 
for injections. Therefore, we decided that the Plan has to reduce the coinsurance for the botox injections 
provided on July 19, 2022. 
 
We also decided that the Plan does not have to reduce the copayment for a specialist office visit provided 
on July 19, 2022. 
 
You have been asked to pay a $32 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services 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 
specialist office visit provided on July 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast cancer gene (BRCA 1 and BRCA 2) analysis 
(codes 81162, 81163, 81164). 
 
You asked the Plan to pre-approve the testing. You say that you have a family history of cancer, and you want 
to know more about the possibility of getting cancer. The Plan denied your request. The Plan says without a 
current cancer diagnosis, the testing 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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not have a personal history of cancer. The documentation does not support that BRCA 1 
and BRCA 2 gene analysis are medically reasonable and necessary for you in this case. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve breast cancer gene (BRCA 1 and BRCA 2) analysis (codes 81162, 81163, 81164).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirements 
for approval. 
 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 pre-approve 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0851, E2363). 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that the group 3 power wheelchair is 
medically necessary. The Plan denied your request. The Plan says there is not a qualifying condition for this 
type of power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair (K0851, E2363).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services 
coded 88342 provided on February 9, 2022. 
 
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 8, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the immunohistochemistry or 
immunocytochemistry services have not been met. Therefore, we decided that the Plan does not have to pay for 
the immunohistochemistry or immunocytochemistry services coded 88342 provided on February 9, 2022.