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

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you would like this claim reprocessed and 
approved for payment. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for new glasses and a box spring provided from June 13, 2020, 
to October 30, 2020. 
 
You asked the Plan to pay for new glasses and a box spring. You say that you live alone, are disabled and live 
from check to check. You also say that your eyeglasses are much overdue, and you count on the reimbursement 
to cover them. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan. The Plan also says that box springs are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from an in-network provider. The rules say 
that for equipment to be covered, it must primarily serve a medical purpose. 
 
We looked at the file and the Plan's rules. The Plan rules say that vision mandatory supplement benefit 
exclusions include, but are not limited to, any benefits received at a non-network optical provider. Additionally, 
the box spring at issue does not serve a purpose that is primarily medical in nature. A box spring is available to 
the general public and would be helpful even to those who are not sick or injured. Based on this information, 
we decided that the Plan's rules for coverage of new glasses and a bed frame have not been met. Therefore, we 
decided that the Plan does not have to pay for new glasses and a box spring provided from June 13, 2020, to 
October 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on May 10, 
2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the criteria for coverage have not 
been met for the services rendered. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90832) provided on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93308, 93321, and 93325 billed for date of 
service May 5, 2022. 
 You asked the Plan to pay for procedure codes 93308, 93321, and 93325. You say that you would like this 
claim reprocessed based on the medical records. The Plan denied your request. The Plan says payment for 
codes 93308, 93321, and 93325 are bundled into payment for code 33361. 
 
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 codes 
93308, 93321, and 93325 are all column II codes to column I code 33361. 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 codes 93308, 93321, and 
93325 billed for date of service May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on April 12, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial. You also say the 
provider regarded this test as a medically necessary valuable tool when determining treatment for the member. 
As stated, the industry standard for emergency and urgently needed services is applicable to coverage 
determination and therefore should be considered in this review of this claim. The Plan denied your request. 
The Plan says the records show that the enrollee's diagnosis is benign neoplasm of bones of skull and face. The 
limited medical records do not show that the enrollee has either recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer. 
 
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 81455 is not supported in the medical record. Specifically, the enrollee does not meet 
the requirements for approval of the requested genetic testing. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing (81455) provided on April 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuedexta. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuedexta.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a specialist telehealth visit provided on January 31, 
2022, to $35. 
 
You asked the Plan to reduce the copayment for the specialist telehealth visit. You say that this was a telehealth 
visit and should only have a $35 copayment. The Plan denied your request. The Plan says that you were 
charged this cost sharing correctly. 
 
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 not forwarded the medical records pertaining to this 
visit. Without this information, we cannot verify the cost sharing applied in this case. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial is not substantiated, so we must 
find in your favor. Therefore, we decided that the Plan has to reduce the copayment for a specialist telehealth 
visit provided on January 31, 2022, to $35.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist (99204) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you want to see an oncologist for a second 
opinion and the Plan has only one oncologist. You say that you had chemo and after a maintenance treatment 
you felt really sick. you were told to get another medication and you now want a second opinion. The Plan 
denied your request. The Plan says you must use network providers to get your medical care and services. 
 
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 
an office visit with an oncologist (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are a kidney 
transplant patient, and you need dialysis twice a week. You do not have any help and you depend on routine 
transportation to get you to and from dialysis appointments. The Plan denied your request. The Plan says you 
have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips 
(A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, anterior interbody technique, including 
minimal discectomy to prepare interspace (22558) and an insertion of interbody biomechanical device(s) with 
integral anterior instrumentation (22853). 
 
You asked the Plan to pre-approve decompression and fusion of the lumbar spine. You say that reconsideration 
is being requested for the enrollee due to kyphosis. The Plan denied your request. The Plan says the requested 
services do not meet the requirements for approval. 
 
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 decompression and fusion of the lumbar 
spine. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and 
failure of recent, reasonable, and comprehensive less invasive conservative care measures. Additionally, 
dynamic flexion/extension films are not provided in order to potentially assess the amount of movement 
(instability) at the requested surgical level. Detailed documentation is not evident regarding potential 
impending/inevitable temporary intra-operative instability. In addition, magnitude of kyphoscoliosis and degree 
of potential decompensation of balance/alignment are not clearly delineated. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of decompression and fusion of the lumbar spine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthrodesis, anterior interbody technique, including minimal 
discectomy to prepare interspace (22558) and an insertion of interbody biomechanical device(s) with integral 
anterior instrumentation (22853).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 3, 2021, billed 
with codes 81210, 81275, 81206, and 81235. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed 
correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 3, 2021, billed with codes 81210, 81275, 81206, and 81235.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee had previously stayed at the SNF and 
was progressing. You say the enrollee fell, and after a brief hospital stay, he needs to return to the SNF in order 
to get stronger. The Plan denied your request. The Plan says the SNF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a long-term care setting with part-time skilled 
services. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. The enrollee does not require skilled nursing or therapy services daily. Based on the medical records 
provided, there is no documentation that daily skilled services are required. Although the record documents that 
the enrollee is limited functionally, there is no significant decline in the enrollee's functional status compared to 
his recent baseline to necessitate daily inpatient skilled therapy services. As a practical matter, the enrollee does 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix Prime skin graft services. 
 
You asked the Plan to pre-approve skin graft services. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 skin graft services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a review of the current medical literature indicates that the requested services are 
considered to be reasonable and necessary for chronic wounds that have failed standard treatment for at least a 
30-day period during organized comprehensive conservative therapy. In this case, the records do not support 
failed conservative wound therapy because the wound measurements do not indicate failed wound management 
over 30 days since only one set of measurements were provided. The review has determined that the 
items/services at issue in this case are not medically reasonable and 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 skin graft services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Grafix Prime skin graft services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos. 
 
You asked the Plan to pre-approve Tymlos. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tymlos.  
 
Benefits for Tymlos may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that the enrollee has prostate cancer, and the 
requested drug is medically necessary. You say that they do not offer Eligard and that the records provided 
support the need for Lupron injection services. The Plan denied your request. The Plan says the enrollee has 
not tried the preferred agent. The Plan says that the enrollee does not have any stated contraindications to the preferred product. The Plan says that the enrollee has not provided a rationale for use of the non-preferred 
product for safety or efficacy. 
 
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 Lupron Depot. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee 
has prostate cancer.  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.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 11, 
2022, to May 16, 2022. 
 
You asked the Plan to pay for SNF care. You say that it is felt that Medicare payment could have been made 
for these services. The Plan denied your request. The Plan says Medicare coverage criteria were not met on 
these dates. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services are not shown to have been required to establish 
a maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 11, 2022, to May 16, 2022.