Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the durable medical equipment (DME) provided on July 
1, 2022. 
 
You asked the Plan to hold you harmless for the DME. You say that the items were medically necessary. The 
Plan denied your request. The Plan says that there was not prior authorization for this item. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the DME by a contract provider. The file does not show that the Plan provided notice 
that the DME would not be covered. Under Medicare rules, this means the DME is considered approved by the 
Plan. While a prior authorization was requested, it was not denied until after the date of service so theres no 
documentation that you were informed of non-coverage before receiving the items. Therefore, we decided that 
the Plan has to hold you harmless for the durable medical equipment (DME) provided on July 1, 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: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 26, 2022, billed with 
procedure code 00732. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is not reported with the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when anesthesia codes are used and MAC has 
been provided, the QS modifier must be used. 
 
We looked at the file and Medicare rules. The claim has not been reported with the required QS modifier. 
Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on March 26, 2022, billed with procedure code 00732.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service March 4, 
2023.  You asked the Plan to pay for procedure code 88360. You say that the pathology report documents the services 
provided. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. The medical records did not sufficiently document why the excess units were 
needed to treat this enrollees condition. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88360 billed for date of service March 4, 2023.
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 the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on August 03, 2023. 
 
You asked the Plan to pay for a psychotherapy visit. You say that this should be covered. 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 a psychotherapy visit 
provided on August 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87086, 87088, 87186) provided on July 13, 
2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the testing provided in this case. The documentation does not contain medical 
records showing the ordering physicians intent that this testing be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services (87086, 87088, 87186) provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 ESI. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has documented spinal stenosis with radicular pain to their buttocks and 
symptoms of neurogenic claudication. 
 
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 ESI have been met. Therefore, we decided that the Plan has to pre-approve 
an ESI.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing.  
You asked the Plan to pre-approve genetic testing. You say that the enrollee has a family history of cancer.  
The Plan denied your request. The Plan says the test is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The testing at issue in this appeal is being requested solely for screening 
purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve the medication. You say that Repatha is medically necessary. 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 Repatha.   
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 pre-approve skin substitute, Kerecis Omega3, surgical preparation 
and application (Q4158, 15002, 15271). 
 
You asked the Plan to pre-approve Kerecis Omega3, surgical preparation and application. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 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 Kerecis Omega3, surgical preparation 
and application have been met. Specifically, medical records were requested but not received. Medical 
necessity cannot be established without this information. Therefore, we decided that the Plan does not have to 
pre-approve skin substitute, Kerecis Omega3, surgical preparation and application (Q4158, 15002, 15271).
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 meets the admission criteria 
for ongoing nutritional support. The Plan denied your request. The Plan says once the enrollee is ready for 
discharge, they can reasonably receive continued care needs in another setting, such as an inpatient 
rehabilitation facility (IRF) or skilled nursing facility (SNF). 
 
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 acute hospital care, and acute care services have not been 
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required 
medical services identified that are available at the LTACH that are not available at the current health care 
setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 6, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
February 23, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue was not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on February 
23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 21, 2023. 
 
You asked the Plan to pay for the lab testing. 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 for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The file shows that a urinary tract infection panel was billed using codes 87500, 87641, 87798, 87491, 87496, 
87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, 87653, and G0452. We looked at the file and 
Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no 
evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a 
single code with one unit of service should be used. Based on this information, we decided that Medicare rules 
for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the panel testing billed for date of service July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urology visit provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for a urology visit. You say that this was a surgical follow up and 
should not have a copayment. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a urology visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a urology visit provided on July 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram services provided on 
August 03, 2023. 
 
You asked the Plan to waive the copayment for an echocardiogram services. You say that you did not receive 
services on this day. 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 $42 
copayment for outpatient hospital services. 
 
You have been asked to pay a $42 copayment for an echocardiogram services. This item/service falls within 
the outpatient 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. The record shows the test results were read on this date of service assessing a 
copayment. Therefore, we decided that the Plan does not have to waive the copayment for an echocardiogram 
services provided on August 03, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on July 10, 2023. 
 
You asked the Plan to pay for the non-emergent services. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergent services. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found there is no evidence that the 
enrollee required the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car) without endangering 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 the non-emergent services have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance services provided on July 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (vedolizumab) injection (J3380). 
 You asked the Plan to pre-approve Entyvio (vedolizumab) injection. You say that this is a medical necessity for 
the enrollee's Crohn's disease. The Plan denied your request. The Plan says the member has not tried and failed 
the preferred step therapy drug Stelara. The Plan also says there is no indication our preferred drug would 
likely be less effective, and/or cause adverse effects for the member. 
 
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 Entyvio (vedolizumab) injection. Our 
reviewer says that the enrollee does not meet the criteria for the requested drug. Our physician reviewer found 
the case file does not contain documentation of trial and failure of Stelara. Our physician reviewer also found 
that the documentation does not support that Stelara would likely be less effective, and/or would likely have 
adverse effects for the enrollee 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 Entyvio (vedolizumab) injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Entyvio (vedolizumab) injection (J3380).