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

 
We decided that the Plan does not have to waive the copayment for an in-network abdominal ultrasound 
provided on August 03, 2023. 
 
You asked the Plan to waive the copayment for an in-network abdominal ultrasound. You say that you thought 
this would be covered 100%. You dont think you should have to pay this 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 $100 
copayment for Medicare-covered ultrasound. 
 
You have been asked to pay a $100 copayment for an in-network abdominal ultrasound. This item/service falls 
within the Medicare-covered ultrasound 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 abdominal ultrasound provided on August 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491, 87563, 87640, 87653, 
87798, 87641 and 87500) provided on June 5, 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 guidelines. 
 
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, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500) provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 10, 2023. 
 
You asked the Plan to pay for chiropractic care. You say that you want this service 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 chiropractic care 
provided on July 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that that you need more time in an LTACH 
for slow weening off the ventilator. You also say that you can get more therapy at the LTACH which will make 
you stronger and aid in your goal of getting of the ventilator. The Plan denied your request. The Plan says 
based on Medicare guidelines, the LTACH services requested do not meet the requirements for approval. 
 
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 was admitted with acute respiratory failure secondary to a traumatic 
pneumothorax. The record indicates that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. Our reviewer found that the enrollee continues to receive acute care 
services, and these have not been denied. Our physician reviewer also found that the medical record does not 
indicate that the enrollee requires services that they are not currently receiving but that would be available at 
the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services. provided on August 06, 
2022, to March 04, 2023. 
 
You asked the Plan to pay for an office visit and related services.. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services. provided on August 06, 2022, to March 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 30, 2023, billed with 
codes 81227, 81231, 81232, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 30, 2023, billed with codes 81227, 81231, 81232, 81306 and 81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilator therapy, the 
enrollee is at high risk for costly hospital readmissions and potentially life-threatening exacerbations. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure that could be delivered by 
BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from COPD. The record indicates that the enrollee was successfully 
treated with BiPAP. Our reviewer found that the provided primary source documentation does not contain 
sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
Our physician reviewer also found that the Plan has indicated coverage for such a device is available upon 
request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Pride Victory Sport scooter (K0899). 
 
You asked the Plan to pre-approve a Pride Victory Sport scooter. You say that you cannot walk and do not 
understand why you have all the doctor's notes and still cannot get the scooter. The Plan denied your request. 
The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
 
  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 Pride Victory Sport scooter. Our 
reviewer says that the group 1 power mobility device or power scooter (K0899) is medically necessary. Our 
physician reviewer found you are non-ambulatory and cannot use a cane or walker for assistance with mobility. 
You are unable to functionally propel a manual wheelchair due to limited upper extremity range of motion and 
pain. Our reviewer found that you require a power scooter for mobility and performing daily activities and have 
been evaluated for one. You can transfer at a modified independent level and are noted to be able to operate a 
power scooter. Your current power scooter is two years in age, but no longer fits you due to your size and 
weight. Our physician reviewer also found that you require a new scooter to safely meet your positioning and 
mobility needs. 
 
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 Pride Victory Sport scooter have been met. Therefore, we decided that the 
Plan has to pre-approve a Pride Victory Sport scooter (K0899).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intra-articular injection of Euflexxa. 
 
You asked the Plan to pre-approve an intra-articular injection of Euflexxa. The Plan denied your request. The 
Plan says there is no information provided showing the enrollee has a diagnosis of osteoarthritis of the knee 
confirmed by x-ray or magnetic resonance imaging, and there is no information showing the enrollee has tried 
and failed physical therapy. 
 
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 intra-articular injection of Euflexxa. 
Our reviewer says that the documentation does not support that an intra-articular injection of Euflexxa is 
medically reasonable and necessary for the enrollee. Our physician reviewer found the records do not show 
failure of at least 3 months of conservative therapy and trial and failure or contraindication to intra-articular 
steroid injections. Our physician reviewer also found that the documentation does not support that the intra-
articular injection of Euflexxa is safe and effective 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 an intra-articular injection of Euflexxa have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intra-articular injection of Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that you have chronic pain. You also say that this 
procedure is necessary to assist in the alleviation of your pain. The Plan denied your request. The Plan says this 
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 the nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical trials. 
Therefore, the reviewer found that the requested genicular nerve block 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve block (64454).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the inpatient hospital care provided on June 2, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford the 
copayment. The Plan denied your request. The Plan says that 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 you must pay a $298 copayment per day, days 1 to 5, for inpatient hospital 
care, and that the day before you are discharged is your last inpatient day. 
 
The Plan says you must pay a $298 copayment for the inpatient hospital care. Based on the Plan contract, 
however, you cannot be asked to pay any cost sharing for the inpatient hospital care since you were admitted 
and discharged on the same day. Therefore, we decided that the Plan has to waive the copayment for the 
inpatient hospital care provided on June 2, 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: 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 the enrollee needs IRF services in order to return to 
prior level of functioning at home. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval of the requested IRF services.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee requires treatment by multiple therapies, including physical and occupational therapy, the services 
required can be provided at a lower level of care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. You say that this is a continuation of treatment. The Plan 
denied your request. The Plan says paclitaxel has low emetic risk. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Palonosetron. Our physician reviewer 
found that the enrollee has a diagnosis of breast cancer and is receiving the requested drug as part of a low 
emetic risk chemotherapeutic regimen. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. Therefore, 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 Palonosetron  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for teeth #1, #2, #3, #4, #5, #6, #7, #8, 
#10, #12, #13, #14, #15, and #16. 
 
You asked the Plan to pre-approve pontics. You say that you have a severe infection and are in pain. The Plan 
denied your request. The Plan says the medical criteria for this dental work have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers pontics when 
the services are medically necessary and reasonable.  
 
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 pontics. Our reviewer says that this 
dental work is not medically necessary. Our physician reviewer found A fixed bridge may be covered to 
replace a single maxillary anterior tooth when there are no missing posterior teeth in the arch. Our doctor found that the required medical criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontics have not been met. Therefore, we decided that the Plan does not have to 
pre-approve pontics (D6240) for teeth #1, #2, #3, #4, #5, #6, #7, #8, #10, #12, #13, #14, #15, and #16.