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

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration due to an 
elevated stroke risk. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 Eliquis.  
 
Benefits for the medication 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99235 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for the billed code. You say that this is the correct code for observation care. The 
Plan denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99235 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. 
 
We find that CPT code 99235 is not supported in the medical record. The records show that the enrollee was 
admitted on July 12, 2023. The records do not show that admission and discharge was on the same date. Based 
on this information, we decided that Medicare rules for coverage of the billed code have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99235 billed for date of service 
July 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of 
zoledronic acid before they will approve the requested drug. 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 and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Levemir FlexTouch. 
 
You asked the Plan to pre-approve the medication. You say that pens are needed because the enrollee is unable 
to draw up insulin from a vial due to dexterity issues. You say the enrollee is out of insulin and needs an 
emergency refill until their mail order prescription arrives. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 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 Levemir FlexTouch.  
 
Benefits for the medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiology services provided 
on June 10, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic radiology services. You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for the diagnostic radiology services. This item/service falls 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the allowed amount is less 
that the copayment, so you are only being charged #224.76 Therefore, we decided that the Plan does not have 
to waive the copayment for the diagnostic radiology services provided on June 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that without this bed, you require help 
from your daughter who works full-time. If you need to use the bathroom, you cannot get into a regular bed 
without assistance. The Plan denied your request. The Plan says total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99223 and 99233) rendered 
from June 29, 2023, to July 1, 2023. 
 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
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 the case pertains to an enrollee 
with alcohol use disorder who had recently been seen for possible cholecystitis but who left against medical 
advice and then presented again to the emergency department with worsening right upper quadrant pain. There 
is no documentation from the date of service that was billed for, just an overall discharge summary. 
 
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 hospital care (procedure code 99223 and 99233) rendered from June 29, 2023, to July 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on January 3, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 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. While the referring provider was a network 
provider, it was not the enrollee's primary care physician (PCP). 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 the wound care services provided on January 3, 2023, by an out-
of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 3, 
2023. 
 
You asked the Plan to pay for code 99285. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
 We looked at the file and Medicare rules. A comparison of the two claim lines shows these are exact 
duplicates. There is no evidence presented to support that the billed services were provided twice on the same 
date. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 3, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the enrollee does not meet all criteria for LTACH. 
 
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 that the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that are not 
currently being provided but that would be available at the LTACH facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a peripheral neurostimulator (64590). 
 
You asked the Plan to pre-approve a peripheral neurostimulator. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 peripheral neurostimulator. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a peripheral nerve stimulator is experimental for chronic-pain treatment. 
 
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 peripheral neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a peripheral neurostimulator (64590).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 21, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary, 
and this claim was coded correctly. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F29 has an Excludes1 note in relation to R46.2. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs (K0108, E1016, E2366). 
 
You asked the Plan to pre-approve wheelchair repairs. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that the Plan does not pay for repair of previously denied equipment or 
equipment in the frequent and substantial servicing or oxygen equipment payment categories.  
 
The records show that the current cost of repairs to the enrollees wheelchair totals $2,677.20. The cost to 
replace the wheelchair is $603. The repairs being requested would be more than the cost to replace the 
enrollees wheelchair. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs 
(K0108, E1016, E2366).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not approved in advance. 
 
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 services at issue in this appeal. 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 services provided on July 17, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services (99457) provided on August 31, 2023. 
 
You asked the Plan to pay for the remote physiologic monitoring treatment management services (99457). You 
say that the service was medically necessary. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the remote physiologic 
monitoring treatment management services (99457) provided on August 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided on 
January 06, 2022, to January 07, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the cost share is 
wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $215 
copayment for inpatient hospital services. 
 
You have been asked to pay a $215 copayment for the inpatient hospital services. This item/service falls within 
the inpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided on January 06, 2022, to January 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and testing with a tertiary level provider. 
 
You asked the Plan to pre-approve the physician services. You say that you need this procedure for all the 
medical issues you have. The Plan denied your request. The Plan says the records do not support the need for 
these services to be performed by a tertiary level provider.  
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 physician services. Our reviewer 
says that the requested physician services to be performed by a tertiary provider are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided documentation does not 
specifically detail why an office visit and testing with a tertiary level provider is 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 the physician services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit and testing with a tertiary level provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you need this item because you cannot get 
up from the toilet. The Plan denied your request. The Plan says raised toilet seats are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 11, 2022. 
 
You asked the Plan to pay for the billed testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The file shows that a Guardant Reveal test was provided. Although 
the claim was billed with a unique identifier, the test has not met Medicares reasonable and necessary 
requirements. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service September 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato (G2082). 
 
You asked the Plan to pre-approve Spravato. You say that this is necessary for the enrollee. The Plan denied 
your request. The Plan says drugs dispensed directly to the enrollee by a pharmacy are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Spravato (G2082).