Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says medical-necessity rules for the requested 
services have not been met. 
 
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 home health services. Our reviewer 
says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer 
found that clinical documentation from the provider states that you miss therapy sessions and are non-
compliant with the therapy plan. The documentation also shows that you are requesting home health care for 
bath aid and not to participate in skilled therapy. The skilled assessment and treatment of professional 
therapists are not needed 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72080 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 72080. The Plan denied your request. The Plan says payment for 
code 72080 is bundled into payment for code 72100. 
 
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 72080 is a column II code to column I code 72100. 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 72080 billed for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on December 15, 2021. 
 
You asked the Plan to pay for the wellness visit. The Plan denied your request. The Plan says the limited 
service has been exceeded. 
 
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 G0439 was previously provided to the enrollee on April 26, 2021. The annual wellness 
visit is only covered once every 12 months. Based on this information, we decided that Medicare rules for 
coverage of the wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the annual wellness visit provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing panel provided on April 19, 
2022. 
 
You asked the Plan to pay for the panel testing. You say that the treatment sought was medically necessary to 
treat the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the pharmacogenetic testing panel provided on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 6, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the plan has a network deficiency for the test. 
The Plan denied your request. The Plan says lab tests must be performed by the contracted laboratory. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on October 6, 2021, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in all four quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that periodontal scaling is not medically necessary. 
 
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 provide the medical records they used in making their decision. 
They have not supported their decision to deny your request. Therefore, we decided that the Plan has to pre-
approve periodontal scaling and root planing in all four quadrants (D4341).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for an IRF admission. 
 
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 while the enrollee may benefit from continued physical therapy, and occupational 
therapy, the enrollee's rehab needs can be safely provided in a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya Injection, tildrakizumab, 1 mg (J3245). 
 
You asked the Plan to pre-approve the injection. You say that the records should support the necessity of the 
service The Plan denied your request. The Plan says the request for Ilumya injection does not meet medical 
necessity as the records do not show that the enrollee has tried Avsola Inflectra or Renflexis. 
 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has plaque psoriasis. The requested medication 
is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred 
step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the Plan's preferred step one alternative. 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya Injection, tildrakizumab, 1 mg (J3245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5050) received on May 21, 2022. 
 
You asked the Plan to pay for hearing aids. You say that the hearing aids were less expensive at the out-of-
network provider. The Plan denied your request. The Plan says the hearing aids were obtained from an out-of-
network provider with no pre-authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only you utilize an in-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids (V5050) received on May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 26, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on March 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a broken right arm and hip, and you have 
an in-stomach feeding tube because you have trouble eating. You also say that your blood pressure is really 
low, and have had multiple surgeries for your esophagus. The Plan denied your request. The Plan says based on 
Medicare guidelines, the request for IRF services does not meet the requirements for approval. 
 
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 patient does not require treatment by multiple therapies, including either 
physician therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician 
reviewer also found that while the medical records support a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Our physician reviewer also found that 
medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection, romosozumab-aqqg, Evenity 1 mg (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee is in severe stage of osteoporosis and 
needs this medication for that reason. The Plan denied your request. The Plan says the records do not show that 
the enrollee has tried one of the preferred drugs Prolia (denosumab) or Reclast (zoledronic acid). 
 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 Evenity. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The Plan requires a trial of Prolia or IV zoledronic acid before they will approve the requested 
drug.  There is no documentation provided indicating that the plans required drugs would 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve injection, romosozumab-aqqg, Evenity 1 mg (J3111).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 2, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone and/or joint imaging; whole body (78306). 
 
You asked the Plan to pre-approve a body scan. You say that medical records are included to show medical 
necessity. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the 
requested body scan. 
 
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 body scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a PSA level was not provided in the records. According to AUA/ASTRO Guidelines, clinicians 
should obtain a bone scan and either pelvic multi-parametric magnetic resonance imaging (mpMRI) or CT scan 
for patients with high-risk prostate cancer (PSA greater than 10, or stage T2 disease). 
 
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 body scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone and/or joint imaging; whole body (78306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 30, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on February 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chronic care management services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 chronic care management services provided on 
February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the services needed 
could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, outpatient 
setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive any amount in excess of your $440 contracted copayment for 
diagnostic colonoscopy services. We decided that the Plan does not have to waive the $440 copayment for a 
diagnostic colonoscopy.  
 
You asked the Plan to waive the copayments for the colonoscopy services provided on April 13, 2022. You say 
that you should not be responsible to pay this. The Plan says that the cost share has been applied correctly. 
 We decided that the Plan has to waive any amount in excess of your $440 contracted copayment for 
diagnostic colonoscopy services.  
 
The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate 
terms all cost-sharing information (such as copayments, deductibles, and coinsurance). 
 
We looked at your request, the file and rules. Your contract with the Plan does not clearly disclose that you are 
responsible for any amount in excess of your $440 copayment for a diagnostic colonoscopy. Therefore, we 
decided that the Plan has to waive any amount in excess of your $440 contracted copayment for diagnostic 
colonoscopy services.  
 
We also decided that the Plan does not have to waive the $440 copayment for a diagnostic colonoscopy. 
 
We looked at your request, the file and rules. Your contract with the Plan says that enrollees must pay a $440 
copayment for an in-network diagnostic colonoscopy. Therefore, we decided that the Plan does not have to 
waive the $440 copayment for a diagnostic colonoscopy. 
 
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.