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

 
We decided that the Plan has to pay for the durable medical equipment provided on August 31, 2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make 
a determination within the allotted time frame. 
 
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 Plan originally denied payment for this claim due to a lack of information 
requested. After this denial, the provider sent in valid medical records. There is no reason for the denial 
anymore, and the plan has not provided any new reasons to continue denying these services. Therefore, we 
decided that the Plan has to pay for the durable medical equipment provided on August 31, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 skilled nursing (SN) visits. 
 
You asked the Plan to pre-approve the SN visits. You say that you and your caregiver are unable to treat the 
wound on your hip. You also say that you have Parkinson's and need help with this. The Plan denied your 
request. The Plan says you do not meet Medicare criteria for the visits requested. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 SN visits. Our reviewer says that 
ongoing home health SN services are not medically necessary or reasonable. Our physician reviewer found you 
do not have documented skilled nursing needs. You have a small pressure injury, requiring simple wound care. 
Our reviewer also found that your caregiver has been taught how to provide the wound care and has 
demonstrated competency of the same. 
 
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 SN visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3 skilled nursing (SN) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you cannot, without pain, go up the steps. This is 
not a comfort/convenience item but a way for you to keep your balance, ease pain and help function in your 
home which is a split foyer type. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the requested IMRT is medically necessary. The Plan 
denied your request. The Plan says the requested IMRT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Intensity-modulated radiation therapy 
(IMRT) have been met. The file shows that multiple attempts were made to obtain medical records for review 
and were not provided to the Plan. Without medical records, we are unable to determine if the enrollee meets 
Medicare criteria for the requested Intensity-modulated radiation therapy (IMRT). The appeal was denied by 
the Plan after a peer to peer was completed with the provider's on-call Urologist, who stated that there is no 
indication for treatment with IMRT. If the treating physician has a different plan of treatment, they need to resubmit an expedited request to the Plan and include complete medical records to support their request. 
Therefore, we decided that the Plan does not have to pre-approve Intensity-modulated radiation therapy 
(IMRT) at this time.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services provided on January 9, 2017. 
 
You asked the Plan to pay for drug testing services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service has been up coded 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of drug testing services have been met. Therefore, we decided that the Plan has to 
pay for drug testing services provided on January 9, 2017.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs, as a practical matter, can be provided at a lower level of care. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the criteria for coverage 
have 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the Plan's preferred step one alternative. Our reviewer found that 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. The elements of the coverage criteria are not satisfied. Our physician reviewer 
also found that 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of the heart without contrast material, with quantitative evaluation of 
coronary calcium. You say that the requested service is medically necessary. The Plan denied your request. The 
Plan says Medicare does not cover the requested study for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. Medicare rules say a CT of the heart without contrast material, with quantitative 
evaluation of coronary calcium is never covered for screening. 
 
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 heart without contrast 
material, with quantitative evaluation of coronary calcium. Our reviewer says that the enrollee does not meet 
coverage criteria for the requested service. Our physician reviewer found Medicare does not cover a screening 
coronary CT angiography for asymptomatic patients, for risk stratification or for quantitative evaluation of 
coronary calcium.  
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 heart without contrast material, with quantitative evaluation of 
coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary calcium 
(75571).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95811). 
 
You asked the Plan to pre-approve a polysomnography. You say that you would like this service to be 
approved for coverage. The Plan denied your request. The Plan says a home sleep study would be appropriate 
and there is no medical necessity for the requested in facility titration sleep study. 
 
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 polysomnography. Our reviewer says 
that the requested polysomnography is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's diagnosis is suspected sleep disorder and clinically established 
narcolepsy. According to the conversation with the provider, there is a clinical concern for sleep disordered 
breathing, specifically obstructive sleep apnea (OSA). The enrollee is being referred for in-lab sleep study 
testing for suspected OSA. Our reviewer found that there is no specific request for management of narcolepsy. 
Although the study would help in clinical management, initial testing would be most appropriate with a home 
sleep study. The enrollee has no medical comorbidities that would preclude referral for home sleep study 
testing. Our physician reviewer also found that the review has determined that the polysomnography 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 a polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (95811).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc (J7329). 
 
You asked the Plan to pre-approve Trivisc. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
 
 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 Trivisc. Our reviewer says that Trivisc 
is not medically reasonable and necessary. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative, Orthovisc or Supartz FX. Our 
reviewer found that 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. The elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that 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 Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc (J7329).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refill kit provided on December 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says no separate payment is made. 
 
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 A4220 is refill kit for implantable infusion pump. We 
find that CPT code A4220 has a status indicator of P, which means that the service is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the refill kit provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy, bone, open (20245) provided September 24, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that due to network insufficiency, the out of 
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in network primary physician and in network facility. The Plan denied your 
request. The Plan says payment is not allowed for an assistant at surgery because it was not required for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20245. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for biopsy, 
bone, open (20245) provided September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says screening services without documentation 
of medical indication from the treating provider is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
January 24, 2022, have been met. In this case, no medical records have been received from the ordering provider that substantiate why the testing was ordered.  Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on January 24, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery services provided on December 9, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for the services provided. You say that prior authorization is not needed. The Plan 
denied your request. The Plan says that the procedure was not pre-certified. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that as a member of the Plan, you can receive your care from either a network provider or an out-of-
network provider.  
 
We looked at the file and Medicare rules. The services were provided at an out-of-network facility. The Plan 
contract shows that a prior authorization is recommended for out-of-network services, but not required. Based 
on this information, we decided that Medicare rules have been met. Therefore, we decided that the Plan has to 
pay for the outpatient surgery services provided on December 9, 2021, by an out-of-network provider.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the heart with quantitative 
review of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the heart is medically necessary 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 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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the enrollee has clinical symptoms 
which may indicate coronary insufficiency despite a negative stress test in November, 2021. In particular, she 
has known peripheral vascular disease and presents with substernal chest pain and dyspnea with exertion. As 
such, she is symptomatic with features compatible with coronary artery disease and is at high risk. She thus 
qualifies per CMS guidelines for the requested CT calcium scoring test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the heart with quantitative review of coronary calcium (75571).  
 
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.