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

 
We decided that the Plan does not have to pre-approve a percutaneous sacroiliac joint arthrodesis (LinQ 
device) 
 
You asked the Plan to pre-approve LinQ device. You say that the enrollee is suffering from lower back pain. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 LinQ device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding imaging or radiographic evidence supporting a 
significant sacroiliitis pathology. Additionally, multiple other plausible pain generators including at the 
lumbosacral spine are evident. Moreover, there are limited large-scale, long-term references showing the safety and efficacy of the requested surgical procedure in this clinical setting. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LinQ device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous sacroiliac joint arthrodesis (LinQ device)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology monitoring services provided on February 
2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for neurophysiology monitoring services. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 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 neurophysiology monitoring services provided on 
February 2, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of intact breast implant. 
 
You asked the Plan to pre-approve breast implant removal. You say that the removal of these implants would 
help checking for cancer. The Plan denied your request. The Plan says this is a cosmetic surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast implant removal. Our reviewer 
says that this surgery is not medically necessary. Our reviewer found the record indicates that the enrollee has a 
history of cosmetic breast implant placement. The record provided does not indicate the presence of a 
complication of the implant. The requested procedure is considered cosmetic.  The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast implant removal have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the removal of intact breast implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on February 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for injections. You say that this should be covered. The Plan denied your request. 
The Plan says this was not authorized. 
 
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 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 injections provided on February 23, 2023, by an 
out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the coinsurance for positive airway pressure (PAP) supplies 
provided on January 19, 2023. 
 
You asked the Plan to waive the coinsurance for positive airway pressure (PAP) supplies. You say that you do 
not think you should owe anything. 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 20% 
coinsurance for in-network Medicare-covered durable medical equipment. 
 
You have been asked to pay 20% coinsurance for positive airway pressure (PAP) supplies. This item/service 
falls within the in-network Medicare-covered durable medical equipment 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 total you owe is $56.39 ($281.93 
allowed amount x 20% = $56.39 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for positive airway pressure (PAP) supplies provided on January 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that admission to a SNF is necessary because the 
enrollee has an arm wound that is being treated frequently. You also say the enrollee needs to be strong, so they 
are not a fall risk. The Plan denied your request. The Plan says the criteria for admission to a SNF are not met.  
 
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 not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health inpatient hospital stay provided from 
November 15, 2022, to November 22, 2022.  
 You asked the Plan to pay for the inpatient behavioral health care. You say that the services were medically 
necessary. You say that the enrollee was getting electroconvulsive therapy at the time. You also say that the 
enrollee's treatment team felt as though the enrollee was not stable, thus discharge did not take place as 
anticipated. The Plan denied your request. The Plan says the enrollee was not posing risk of imminent harm to 
self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient behavioral health care. Our 
reviewer says that the inpatient behavioral health care was not medically necessary. Our physician reviewer 
found the records provided for the admission of the enrollee do not meet the criteria for November 15, 2022, 
forward as the enrollee was not shown to be a danger to themselves or others, delusions, auditory or visual 
hallucinations noted. The reviewer found that the enrollee was cooperative/compliant with treatment while not 
showing any threats the safety. Therefore, the reviewer found that the inpatient behavioral health care was not 
medically reasonable or 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 inpatient behavioral health care have not been met. Therefore, we decided 
that the Plan does not have to pay for the behavioral health inpatient hospital stay provided from November 15, 
2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided 
on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nail fungal polymerase chain reaction (PCR) panel 
rendered on February 16, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed. The Plan denied your 
request. The Plan says the testing exceeds the enrollee's needs. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the long-standing standard of care for the evaluation of fungus in toenails is the performance of both 
potassium hydroxide (KOH) and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollees left hallux toenail required PCR testing as 
compared to KOH and fungal culture. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a nail fungal polymerase chain reaction (PCR) panel rendered on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig, any type (A9282) purchased July 27, 2022. 
 
You asked the Plan to pay for a wig. You say that that Plan had reimbursed you for your last wig that you 
purchased. You were never to where you needed to purchase your wig from. The Plan denied your request. The 
Plan says this is not covered under the Plan benefits. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig, any type 
(A9282) purchased July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network denosumab injection 
provided on January 27, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network denosumab injection. You say that you had 
already paid a copayment at the time of this visit. You should not owe anything else. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay the allowed amount of $68.41 which is less than the $254.46 (20%) coinsurance 
for an in-network denosumab injection.  This item/service falls within the Medicare Part B prescription drugs 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 coinsurance for an in-network denosumab injection provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 27, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these items do not require prior 
authorization. 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 wound care supplies 
provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on January 25, 2023, to April 04, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 total allowed amount for the DME is $576.45. You are being asked to 
pay $115.29 ($576.45 x 20% = $115.29). Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment (DME) provided on January 25, 2023, to April 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four additional units of procedure code 88374 rendered on 
November 18, 2022. 
 
You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says there was no specific rationale for the additional units.  
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 88374 is "Morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe 
stain procedure." 
 
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 additional services. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the enrollee underwent a 
bone marrow biopsy and had cytogenetics testing performed. According to the documentation provided, there 
is no evidence that four additional units were not rendered. Additionally, the additional services would not be 
considered reasonable or necessary. 
 
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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for four additional units of procedure code 88374 rendered on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
January 30, 2023. 
 You asked the Plan to pay for the laboratory service. You say that please fin appeal information that describes 
medical necessity of the PrismRA test to inform consideration of payment. 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory service 
have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted molecular 
pathology procedure (81479) provided January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 88341 rendered on 
March 24, 2023. 
 You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says there was no specific rationale for the extra units. 
 
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
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 additional services. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that according to the medical 
documentation provided, an additional unit of CPT 88331 was not rendered. Additionally, these additional 
services would not be considered medically reasonable or necessary. 
 
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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for an additional unit of procedure code 88341 rendered on March 24, 2023.