Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergent transportation services from the hospital to an 
assisted living facility provided on July 31, 2023. 
 
You asked the Plan to pay for the non-emergent transportation services. You say that the enrollee was 
disoriented at time of transfer and required a stretcher for a safe transport. The Plan denied your request. The 
Plan says that the services were not medically necessary. 
 
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 transportation services. 
Our reviewer says that the non-emergent transport services were medically necessary. Our physician reviewer 
found the enrollee has dementia and was only oriented once in the emergency room. Therefore, this enrollee 
required a higher-level transport personal. The documentation supports that the enrollee needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe 
transport. The non-emergent transport services provided on July 31, 2023, were 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 non-emergent transportation services have been met. Therefore, we decided 
that the Plan has to pay for the non-emergent transportation services from the hospital to an assisted living 
facility provided on July 31, 2023.  
 
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 a continuation of care with an out-of-network (OON) 
pain management specialist. 
 
You asked the Plan to pre-approve the OON service. You say that you were on a regimen with pain in your 
right hip before you had it replaced. You say that you are due for a pain injection and want to the see the 
Orthopedic Surgeon who performed the left hip replacement. The Plan denied your request. The Plan says  it is 
not medically necessary to receive the requested services from an OON provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON service. Our physician reviewer found these services are available 
within the network. There are no extraordinary circumstances documented. The request is 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 the OON service have not been met.  
 
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 the OON service. Therefore, we decided that the Plan 
does not have to pre-approve a continuation of care with an out-of-network (OON) pain management specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair headlights replacement (K0108, 
K0739). 
 
You asked the Plan to pre-approve replacement headlights. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the requested item is not 
primarily medical in nature. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair headlights replacement (K0108, K0739).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87500, 87640, 87641, 87653 
and 87798) provided on March 3, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare rules. 
 
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.  
 
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 laboratory panel (87481, 87500, 87640, 87641, 87653 and 87798) provided 
on March 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tobramycin (J7682). 
 
You asked the Plan to pre-approve tobramycin. You say that your patient has pseudomonas recurrent 
pneumonia along with chronic obstructive pulmonary disease (COPD) and chronic hypoxemic respiratory 
failure. You also say that you would like the denial to be reconsidered based on the provided information. The 
Plan denied your request. The Plan says this drug is not covered per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that it is reasonable and necessary to administer 
tobramycin (J7682) to a beneficiary with cystic fibrosis or bronchiectasis. The rules also say that Medicare may 
pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or 
appropriate for the particular use.   
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 tobramycin. Our reviewer says that this 
request is not medically necessary. Our physician reviewer found the patient has been diagnosed with 
pseudomonas recurrent pneumonia along with chronic obstructive pulmonary disease (COPD) and chronic 
hypoxemic respiratory failure. Tobramycin was requested. However, this medication is not FDA approved for 
this indication due to lack of sufficient high-quality support for such. Our reviewer also found that currently 
this medication is only indicated for cystic fibrosis patients with pseudomonas pneumonia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tobramycin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tobramycin (J7682).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis billed with code L1820 for July 6, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. The file shows that the provider billed place of 
service (POS) code 11 for an office setting. The item is not covered in this setting. Therefore, we decided that 
the Plan does not have to pay for the knee orthosis billed with code L1820 for July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that you have a lot of pain in your knees 
all the time. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy and is the subject of ongoing clinical trials. Therefore, 
the request is deemed 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87581, 87640, 
87651, 87653, and 87798 for April 24, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 
87581, 87640, 87651, 87653, and 87798 for April 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine tablets. 
 
You asked the Plan to pre-approve the medication. You say that Promethazine 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 Promethazine tablets.   
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tobramycin (J7682). 
 
You asked the Plan to pre-approve tobramycin. You say that considering the patient's medical history, current 
medical condition, and the supporting uses of tobramycin for inhalation, you believe treatment with this drug is 
warranted, appropriate, and medically necessary for this patient. The Plan denied your request. The Plan says 
this drug is supported for use in a nebulizer for lower respiratory tract infection. The Plan also says that this use 
is not listed under Medicare's Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 tobramycin. Our reviewer says that this 
request is not medically necessary. Our physician reviewer found the patient does not have a condition which is 
indicated for coverage. Currently, tobramycin is only FDA-approved for pseudomonas colonization in the 
setting of cystic fibrosis patients or via eye drops which does not describe this patient's clinical situation. Our 
reviewer also found that the compendium also does not sufficiently support the patient's condition as an 
indication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tobramycin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tobramycin (J7682).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and 
segmental pneumatic appliance (E0671) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that please 
provide out of network authorization for LymphaCare. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 
the pneumatic compression device (E0652) and segmental pneumatic appliance (E0671) to be provided by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 8, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that it took more time to get the 
correct primary payer information, which caused you to file the claim to the Plan after the filing limit. The Plan 
denied your request. The Plan says the claim was untimely, and the submission did not meet the exception 
criteria guidelines outlined in 42 CFR Section 424.44. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent nursing facility care was not filed until May 1, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on  
April 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient substance abuse detoxification admission. 
 
You asked the Plan to pre-approve an inpatient substance abuse detoxification admission. The Plan denied your 
request. The Plan says based on Medicare guidelines, the admission to an inpatient substance abuse 
detoxification care requested is not approved. 
 
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 an inpatient substance abuse 
detoxification admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found based on review the records provided, the 
patient has shown no mood instability, thoughts of harming himself or others. There is no documentation of 
withdrawal or abnormal vital signs. Our reviewer found there is no documentation of this patient needing 24-
hour treatment. The patient did not have any delusions or hallucinations and did not have any auditory or visual 
hallucinations. Our physician reviewer also found that based on review the records provided, this patient does 
not meet the criteria for treatment at a residential level of care/detoxification and could be treated at a lesser 
restrictive environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient substance abuse detoxification admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an inpatient substance abuse detoxification 
admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GIAnomics Oncology Germline Comprehensive Test 
Panel provided on June 12, 2023, and billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 
81321, 81351, 81403, 81404, 81405, 81406, 81407, 81408, and 81479. 
 
You asked the Plan to pay for the GIAnomics Oncology Germline Comprehensive Test Panel. You say that this 
testing was medically necessary. The Plan denied your request. The Plan says this testing should be billed with 
a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the GIAnomics Oncology Germline 
Comprehensive Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
GIAnomics Oncology Germline Comprehensive Test Panel provided on June 12, 2023, and billed with codes 
81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 81408, 
and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on August 09, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that you went 
in for a screening colonoscopy, which should have been covered at 100%. 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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for an in-network diagnostic colonoscopy. 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. Therefore, we decided that the Plan does not have to waive the copayment 
for an in-network diagnostic colonoscopy provided on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on July 3, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you would like a prompt 
review of this appeal and approval of this approved service. The Plan denied your request. The Plan says over 
the counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on July 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 1, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that this provider has been credentialed with the Plan 
since July 1, 2022. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient mental health care.  
 
The item or service you asked the Plan to pay for falls within the outpatient mental health care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible, 
which applies to outpatient mental health care. This cost sharing is a contractual obligation that had not been 
met at the time psychotherapy was received on March 1, 2023. Therefore, we decided that the Plan does not 
have to pay for psychotherapy provided on March 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 15, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are unsure if the provider 
submitted all documentation to get paid correctly or if she really owes this balance since it has been so long 
since the procedure was done. 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 $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $225 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
June 15, 2022.