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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 10 one-way 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 additional routine transportation.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Human Papillomavirus (HPV) testing (87624) provided on June 13, 
2022. 
 
You asked the Plan to pay for HPV testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says that this code is not covered under Medicare rules. 
 
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 rules also say that code 87624 is not covered for a given beneficiary on the same date of service 
when other testing codes are billed. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any documentation showing other testing was billed 
on the same date of service to support that this code is not covered. Therefore, we decided that the Plan has to 
pay for Human Papillomavirus (HPV) testing (87624) provided on June 13, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97014 and 97110 billed for date of service 
June 7, 2022 to June 29, 2022. 
 
You asked the Plan to pay for procedure codes 97014 and 97110. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 97110 is bundled into payment for 
code 97150. Code 97014 is ineligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 97110 
is a column II code to column I code 97150. Code 97014 has a status of "I" which means it is invalid for 
Medicare purposes. 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 97014 and 97110 billed for date of service June 7, 2022 to June 29, 2022.
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 you are requesting an expedited reconsideration 
for the denial of a SNF admission due to medical necessity. The Plan denied your request. The Plan says the 
enrollee does not meet the medical necessity and established criteria for the requested SNF admission. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 You asked the Plan to pre-approve Darzalex Faspro. 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. 
 
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 Darzalex Faspro. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550 and A4649 billed for April 14, 2022. 
 
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 included in the ASC payment. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulatory surgical center (ASC) payment is 
made for approved procedures only. 
 
We looked at the file and Medicare rules. Billed procedure codes A4550 and A4649 are not included as those 
eligible for ASC payment. 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 procedure codes 
A4550 and A4649 billed for April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve artificial leg, below knee to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve artificial leg, below knee. You say that you are an in-network provider. The 
Plan denied your request. The Plan says the service is available in-network. 
 
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve artificial leg, 
below knee to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life-Alert system. 
 
You asked the Plan to pre-approve a Life-Alert system. You say that a Life-Alert is essential for your well-
being.  You said that you live alone, and you have had two incidents of chronic heart failure. You said that if 
you didn't have a Life-Alert, these may have been fatal.  You said that your daughter has been paying for the 
cost of this device but can no longer do so. The Plan denied your request. The Plan says this device is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems (such as Life-Alert) are 
not covered. Therefore, we decided that the Plan does not have to pre-approve a Life-Alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift, expandable controller, Q-logic controller, and 
assembly labor for a power wheelchair (E2300, E2377, E2313, E2311, K0108, A9900, A9900). 
 You asked the Plan to pre-approve the power wheelchair accessories.. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage rules are not met for the requested 
accessories. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Power seat elevation features are non-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 power wheelchair accessories.. Our 
reviewer says that the requested features are not medically necessary. Our physician reviewer found the records 
show that the enrollee is capable of operative the wheelchair's power features using the standard controls. The 
expandable controller is not medically necessary. The Q-Logic controller is not separately billable from the 
expandable controller. A power seat elevation feature is non-covered under Medicare rules. Assembly labor is 
included in the base payment for the wheelchair. 
 
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 power wheelchair accessories. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a seat lift, expandable controller, Q-logic controller, and assembly 
labor for a power wheelchair (E2300, E2377, E2313, E2311, K0108, A9900, A9900).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
rehabilitation needs can be provided in an alternate and low intensity setting such as in a skilled nursing facility 
or continued in-home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion, drug-delivery implant (ie, bioresorbable, 
biodegradable, non-biodegradable) rendered on December 19, 2022. 
 
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 procedure code 11981 (1 Unit) remains 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 11981 is "Insertion, drug-delivery implant (ie, 
bioresorbable, biodegradable, non-biodegradable)." 
 
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 documentation does not 
support that a biodegradable implant used to deliver long term drug management was inserted in this case. 
 
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 insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non-biodegradable) rendered 
on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOneHeme comprehensive genomic profile 
test. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of acute 
myeloblastic leukemia, not having achieved remission. On March 8, 2021 it is documented that she is now on 
first-line therapy with Vidaza/Venetoclax and is getting a good response and tolerating well. The clinical 
Cancer Institute records from November of 2020 do not support that the enrollee had either recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer. The documentation is insufficient to support that the 
testing was medically reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOneHeme comprehensive genomic profile test.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for open or surgical arthroscopic procedures on knee joint; 
total knee arthroplasty rendered on July 11, 2022. 
 
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 that Current Procedural Terminology (CPT) code 01402-AA (101 Units) remains 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 01402 is "Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty." 
 
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 supported by the medical records. Our reviewer found that in this case, the anesthesia time is 
09:58 - 11:37 (which is 99 minutes/15 minutes = 6.6 units. The time for the administration of the spinal 
anesthetic = 09:54-09:56 = 2 minutes. Added to above (99 min+ 2 min= 101 min). There are 7 base units for 
CPT 01402. The spinal anesthetic was administered at 09:54-09:56. This does count in the time for the 
intraoperative time. Therefore, 99 minutes + 2 minutes (spinal) equals 101 minutes total intraoperative time for 
the total knee arthroplasty. Therefore, 101 units for CPT 01402 is supported. The review has determined that 
the records support that 101 minutes (6.73 units x the conversion factor) is appropriate for the billing of CPT 
01402, rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty rendered on July 
11, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. 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. 
 
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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair rendered on November 24, 2022. 
 
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 only allowed once every 28 days. 
 
The Plan must follow Medicare rules. The rules say that, for capped rental items, Medicare pays the fee 
schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. 
 
We looked at the file and Medicare rules. The file shows that the claim for these services was paid for date of 
service November 15, 2022 which is nine days prior to the denied date of service. 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 standard wheelchair rendered on November 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an OralCDx brush test rendered on September 7, 2022. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says these services do not meet the requirements of the enrollee's plan of benefits. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
per the reviewed literature, esophageal brush biopsy (WATS3D, formerly known as EndoCDx) is considered experimental and investigational for screening, diagnosis or surveillance of cancerous or pre-cancerous 
esophageal lesions because of insufficient evidence. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an OralCDx brush test rendered on September 7, 2022.