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

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
in the setting of chronic renal disease. He has not tried and failed the Plan's required drugs, Ferrlecit, Infed, and 
Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Injectafer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 laboratory services provided on January 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service February 27, 
2022. 
 
You asked the Plan to pay for procedure code 99231. You say that separate procedures were performed, and 
the claim should be reprocessed. The Plan denied your request. The Plan says payment for code 99231 is 
bundled into payment for code 44180. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99231 
is a column II code to column I code 44180. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99231 billed for date of service February 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keresis Omega 3 and application for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says services considered not reasonable and necessary to the standards of Original Medicare 
are not covered under any condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Keresis Omega 3 is a decellularized intact fish skin developed for the management of chronic 
wounds. There is insufficient evidence in the medical literature to support that the application of Keresis 
Omega 3 is an effective treatment for the management of chronic pressure ulcers. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keresis Omega 3 and application for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were billed appropriately and are 
supported in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place 
of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral brow lift repair. 
 
You asked the Plan to pre-approve a bilateral brow lift repair. You say that a bilateral brow lift repair is 
medically necessary. The Plan denied your request. The Plan says a bilateral brow lift repair does not meet the 
Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 bilateral brow lift repair. Our reviewer 
says that a bilateral brow lift repair is not medically necessary. Our physician reviewer found in this case the 
record indicates that the enrollee has dermatochalasis. The record indicates that the MRD1 is 3.5 mm 
bilaterally. The record indicates intact levator function. Photographs were reviewed. The record provided is 
insufficient to establish that the coverage criteria are satisfied. The elements of the coverage criteria are not satisfied.  The requested service is not 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 a bilateral brow lift repair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral brow lift repair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level (code 22869). 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar, single 
level. You say that insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar, single level is medically 
necessary. The Plan denied your request. The Plan says insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level 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 insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level. Our reviewer says that insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar, single level is not considered medically reasonable and necessary. Our physician reviewer 
found interspinous process distraction devices are experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar, single level have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, 
including image guidance when performed, lumbar, single level (code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide purchased on October 1, 2020. 
 
You asked the Plan to pay for a stair glide. You say that you would like this claim reprocessed as this was 
necessary for your condition. The Plan denied your request. The Plan says this is not a covered item according 
to Medicare rules. 
 
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 pay for a stair glide purchased on October 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not a requirement for daily skilled nursing or skilled therapy in a 
skilled nursing facility (SNF) setting. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that based on 
the medical records provided, there is no documentation that the patient requires skilled nursing services, i.e., 
the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory 
care. There is no documentation that daily skilled services are required. Although records document the patient 
is very limited functionally, provided records do not document a significant decline in the patients functional 
status compared to her recent baseline to necessitate daily inpatient skilled therapy service. There is no 
documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not document that services in a long-term care facility on a part time basis are not 
appropriate 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 3, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that procedure code 76942 was used for the 
placement of femoral nerve injection and modifier 26 unbundles it. The Plan denied your request. The Plan 
says payment for code 76942 is bundled into payment for code 76937. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76942 
is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on 
October 28, 2021. 
 
You asked the Plan to pay for a targeted genomic sequence analysis. You say that these services were 
medically necessary and reasonable. The Plan denied your request. The Plan says testing for the FANCC gene 
is not a Medicare benefit and is excluded from coverage. Single tests and panels which include testing for the 
FANCC gene are denied as non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests 
that include the FANCC gene. 
 
We looked at the file and Medicare rules. The requested panel in this case included testing for the FANCC 
gene. Based on this information, we decided that Medicare rules for coverage of a targeted genomic sequence 
analysis have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic 
sequence analysis (0037U) provided on October 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for date of service March 28, 
2022, through March 31, 2022. 
 
You asked the Plan to pay for procedure code H2017. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
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 H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for date of service March 28, 2022, through March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac implantable device. 
 
You asked the Plan to pre-approve a cardiac implantable device. You say that a cardiac implantable device is 
medically necessary. The Plan denied your request. The Plan says a cardiac implantable device does not meet 
the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 cardiac implantable device. Our 
reviewer says that a cardiac implantable device is not medically necessary. Our physician reviewer found there 
is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an implantable loop recorder (ILR). In summary, there is insufficient documentation to 
support the medical necessity for insertion of an ILR 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 cardiac implantable device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cardiac implantable device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 19, 2021. 
 
You asked the Plan to pay for ambulance services. You say that this service was not hospice related. The Plan 
denied your request. The Plan says original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for an eye examination (92004) and 
refraction (92015) provided on March 3, 2022. 
 
You asked the Plan to pay an additional amount for an eye examination and refraction. You say that you want 
the Plan to pay an additional amount for these services. The Plan denied your request. The Plan says the cost 
share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $203 deductible which applies to vision services.  
 
The item or service you asked the Plan to pay an additional amount for falls within the benefit category vision 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 
deductible which applies to vision services. This cost sharing is a contractual obligation that had not been met 
at the time an eye examination and refraction was received on March 3, 2022. Therefore, we decided that the 
Plan does not have to pay an additional amount for an eye examination (92004) and refraction (92015) 
provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that the medical records support the anesthesia 
services. You say that the service should be covered under the authorization for the surgeon and facility. The 
Plan denied your request. The Plan says procedure code 01480 has been approved and procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service February 26, 2022.