Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you have pain in your knee. The Plan denied your 
request. The Plan says you have not tried and failed one of the preferred drugs. 
 
 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 Gel-One. Our physician reviewer found 
that you have osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial of 
Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. The provided records do not 
indicate that you have tried and failed the Plan's preferred step one alternative. The record does not indicate that 
you have 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. 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80307, 83789) provided on August 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 80307 is 
not supported by the records provided. Our reviewer found that the components of CPT code 80307 have not 
been met, as there is no documentation of a chemical analyzer to perform presumptive testing. 
 
We looked at this coder'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. 
 
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 the lab services (80307, 
83789) provided on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the cervical spine provided on December 23, 2021, billed with code 72125-26.  
 
You asked the Plan to pay for the CT Scan interpretation. You say that a copy of the explanation of benefits 
from the incorrect insurance payer was dated within the timely filing limit. The Plan denied your request. The 
Plan says the member was under hospice election for this date of service. Therefore, claim is the 
responsibility of traditional Medicare. 
 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 member 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 the interpretation of the computed tomography (CT) scan of 
the cervical spine provided on December 23, 2021, billed with code 72125-26.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care (99223) provided on April 25, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the payment for this service is included in the fee for the procedure. 
 
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 did not substantiate their denial for the services. They did not provide 
documentation to verify this service is included in the fee for a procedure. The services reported are supported 
in the medical records provided. Therefore, we decided that the Plan has to pay for inpatient hospital care 
(99223) provided on April 25, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on June 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. There is no indication that the 
enrollee received parental/IV feeding or wound care to a surgical site and that the 3rd alphanumeric character 
in the PDPM was correct. The partial adjustment to PDPM GAYE1 was appropriate. 
 
We looked at this coder'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 pay for skilled nursing facility (SNF) services provided to the enrollee on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx Genetic Panel testing provided on 
September 20, 2022.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is covered for 
the indications established in the applicable NCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
does not have either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. This member 
has a Stage 1B (CT2, CN0, CM0) malignant pancreatic head mass. There is no definite evidence of local 
progression, peritoneal or other distant metastatic disease documented.  The requested FoundationOne CDx 
Genetic Panel is not medically reasonable or necessary according to the coverage criteria in the NCD. 
 
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 pay for the FoundationOne CDx Genetic Panel testing provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve continued use of CPAP device. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that continued use of a CPAP device is covered for the 
indications established in the applicable LCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued use of CPAP device. Our 
reviewer says that the requested continued use of CPAP device is not medically reasonable and necessary in 
this case. Our physician reviewer found that the record sent by the provider indicates the enrollee may have 
used this device. However, in the appeal you state "I acknowledge that I have not yet used the machine due to 
the fact that I struggled to understand the written directions and initially became frustrated." You say that you 
did try to get help from the provider of the device. You also say, "I admit that I did not begin using the machine 
out of frustration but am interested in using it to determine if my sleep apnea can be improved." However, there 
is no submitted objective evidence/documentation such as a printed compliance report, to show that you are 
benefiting from CPAP therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of CPAP device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued use of continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01996) provided on August 2, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the original claim submitted includes the 
anesthesia minutes. The Plan denied your request. The Plan says the anesthesia minutes are missing from this 
claim, and therefore this service cannot be paid. The stop and start time for this service must be noted. 
 
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. The rules say that time units are not recognized for procedure code 01996. 
Code 01996 should be reported with a start and end time for the services provided. 
 
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 anesthesia services have been met. 
Specifically, the provider billed code 01996 and did not correctly report the time spent providing these 
services. Therefore, we decided that the Plan does not have to pay for anesthesia services (01996) provided on 
August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this lab service should be paid at the full Medicare 
rate. 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, for 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 January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care to facilitate increased 
independence to return home. The Plan denied your request. The Plan says the enrollee does not meet all the 
required criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the enrollee may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says criteria for an IRF admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the patient requires an intensive inpatient rehabilitation therapy program. The medical records do 
not clarify that treatment at the skilled nursing facility level is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228 and 93229). 
 
You asked the Plan to pre-approve the external mobile cardiovascular telemetry with electrocardiographic 
recording. You say that you would like to appeal this service. The Plan denied your request. The Plan says the 
continuous live-monitoring of electrical activity of your heart with the capability of immediate review by a 
doctor requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a cardiac event detection (CED) service is medically 
unnecessary if it offers little or no potential for new clinical data beyond that which has been obtained from a 
previous test, or if other tests are better suited to obtain the clinical data relevant to the patient's condition. 
 
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 external mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that the external mobile cardiovascular 
telemetry with electrocardiographic recording is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee has frequent, daily palpitations. There is no supportive evidence that the 
ordering practitioner documented any standard, non-mobile cardiac outpatient telemetry (MCOT), ambulatory 
electrocardiogram monitoring. Our reviewer also found that there is insufficient documentation to support the 
medical necessity for an MCOT monitor 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 the external mobile cardiovascular telemetry with electrocardiographic 
recording have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile 
cardiovascular telemetry with electrocardiographic recording (93228 and 93229).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to lower the copayment for the outpatient diagnostic tests outpatient diagnostic 
tests. We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests.  You asked the Plan to waive the copayment for outpatient diagnostic tests provided on March 10, 2022.. You 
say that you disagree with the copayment. 
 
We decided that the Plan has to lower the copayment for the outpatient diagnostic tests.  
 
 Therefore, we decided that the Plan has to lower the copayment for the outpatient diagnostic tests. From 
$75.13 copayment to the amount the Plans EOC states of $75. 
 
We also decided that the Plan does not have to waive the copayment for the outpatient diagnostic tests. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for the outpatient diagnostic tests. Therefore, we decided that the Plan does not have to waive the 
copayment for the outpatient diagnostic tests. 
 
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: Favorable

 
We decided that the Plan has to pay for laboratory services (81455) provided on July 25, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says that they were unable to render a 
decision on this case 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. Specifically, the Plan has provided no clear reason for denial, nor has the Plan 
provided any supporting citation or relevant documentation to support the denial of this claim. Therefore, we 
decided that the Plan has to pay for laboratory services (81455) provided on July 25, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chemotherapy administration (96413), chemotherapy 
administration, each additional sequential infusion (96417), and pertuzumab (J9306) provided on August 9, 
2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the services were experimental in nature. 
 
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 file does not support the Plan's reason for denial. The provided 
documentation does not support the services are experimental. Therefore, we decided that the Plan has to pay 
for the chemotherapy administration (96413), chemotherapy administration, each additional sequential infusion 
(96417), and pertuzumab (J9306) provided on August 9, 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.