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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for continued SNF care. 
 
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 that there are no identifiable skilled nursing or skilled therapy service needs. The 
enrollee does not require these services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria on 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 continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant CDx test billed for date of service March 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test determines if there was a more effective 
therapy to treat the enrollee. The Plan denied your request. The Plan says that the physician's order does not 
include what test is to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The records submitted show that a Guardant 360 CDx test was requested.  
The submitted requisition form is for the specific test at issue. The claim does show that the required unique 
identifier was reported. Furthermore, the enrollee was referred for the testing by a contract provider. Based on 
this information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, 
we decided that the Plan has to pay for the Guardant CDx test billed for date of service March 12, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that the services are medically necessary, and the enrollee 
has tried and failed Orthovisc. The Plan denied your request. The Plan says the enrollee has not met the step-
therapy criteria. 
 
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 Gel-One. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found the enrollee has not tried a preferred 
viscosupplemental treatment such as, Durolane, Monovisc or Synvisc-One. Step therapy, as outlined by the 
plan, requires that one of the preferred viscosupplemental treatments be tried first. The documentation does not 
outline contraindications or reasons these medications were not considered or that the plan's additional required 
drugs would likely be less effective or likely have adverse effects for the enrollee. Without the support of the 
documentation, Gel-One is not approved as the step-therapy criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous insulin treatment (OIVIT) billed 
with codes 99214-25, 96365-59, 96366-59, and 96521 for April 3, 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
We looked at the file and Medicare rules. The services at issue are OIVIT. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the outpatient intravenous insulin 
treatment (OIVIT) billed with codes 99214-25, 96365-59, 96366-59, and 96521 for April 3, 2023.
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 the reasons for denial seem to be invalid for 
the enrollee's situation. You also say that you would consider average volume-assured pressure support 
(AVAPS) auto-expiratory positive airway pressure non-invasive ventilation (NIV) therapy medically necessary 
in this enrollee to prevent hospitalizations and exacerbations. The Plan denied your request. The Plan says the 
home ventilator requested does not meet the requirements for approval. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found this patient has a diagnosis of 
severe COPD, although there are no pulmonary function test results provided to confirm the severity. The 
appeal note indicates an arterial blood gas on June 22, 2023, showed a measure of the acidity or alkalinity of a 
fluid of 7.39 and a partial pressure of carbon dioxide (PaCO2) of 51, but the patient's circumstances at the time 
of the blood gas are not provided. Our reviewer found that if this patient has chronic carbon dioxide (CO2) 
retention, as documented on an arterial blood gas done while stable, may benefit from BiPAP with AVAPS- 
auto-expiratory positive airway pressure during sleep as an outpatient. The AVAPS- auto-expiratory positive 
airway pressure mode can be provided with BiPAP.  Our physician reviewer also found that Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trudhesa. 
 
You asked the Plan to pre-approve the medication. 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 Trudhesa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for dental fillings () provided on April 28, 
2023. 
 
You asked the Plan to waive the cost-sharing for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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. 
 
You have been asked to pay a $100 deductible and 50% coinsurance for dental fillings. This item/service falls 
within the Class 2 Dental 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 cost-sharing for dental fillings () provided on 
April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the Life2000 ventilator (E0466, 3 months). 
 
You asked the Plan to pre-approve the Life2000 ventilator. You say that the enrollee needs a ventilator because 
of the backup battery and alarms to assist improving their symptoms. You also say that without access to 
respiratory support, the enrollee is at risk for decompensation/exacerbation, hospitalization, and death. The 
Plan denied your request. The Plan says that this ventilator is not capable of providing full ventilatory support. 
The Plan says there is insufficient evidence of benefit in the treatment of chronic obstructive pulmonary disease 
(COPD). The Plan also says this is not medically necessary. 
 
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 the Life2000 ventilator. Our reviewer 
says that the requested Life2000 ventilator is not medically necessary. Our physician reviewer found the 
provided documentation indicates the enrollee has chronic obstructive pulmonary disease (COPD) and newly 
diagnosed amyotrophic lateral sclerosis (ALS), therefore, will continue to progress and deteriorate. The 
reviewer found that the documentation does support the requested ventilator. Therefore, the reviewer found that 
the requested Life2000 ventilator is 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 Life2000 ventilator have been met. Therefore, we decided that the Plan has 
to pre-approve the Life2000 ventilator (E0466, 3 months).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305 and 88342 billed for date of service 
November 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are billable and payable. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on November 30, 2022. A comparison of the two claims shows the claim lines are duplicates. There is no 
evidence to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 88305 and 88342 billed for date 
of service November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic testing (81225, 81226, 8227, 81230, 
81231, 81240, 81241, 81291, 81328, 81355, 81401 and 81479) provided on March 23, 2023. 
 
You asked the Plan to pay for pharmacogenomic testing. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says the criteria for coverage of this testing are not met. 
 
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 pharmacogenomic testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation provided does not support that the criteria for coverage of these 
services are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pharmacogenomic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for pharmacogenomic testing (81225, 81226, 8227, 81230, 81231, 81240, 81241, 
81291, 81328, 81355, 81401 and 81479) provided on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
receiver. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM receiver. You say that your family doctor, heart 
surgeon specialist, and general doctor all recommended to put in this special order for a Dexcom G7 to be 
approved because it is needed to maintain your health and keep you out of the hospital. The Plan denied your 
request. The Plan says there has not been sufficient evidence to justify payment for a non-covered device. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. Medicare 
rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the 
preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure 
that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The 
rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under 
a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
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 Dexcom G7 CGM receiver. Our 
reviewer says that you do not meet criteria for CGM coverage at all given the data provided. Our physician 
reviewer found you are not using insulin or having low blood glucoses that we are told of, although the 
medication list includes insulin pen needles. We are not told of insulin use and it seems as if you had been on 
Victoza in the past which requires pen needles. Our reviewer also found that if you did meet criteria for a 
CGM, there is no reason to require the Dexcom brand since the FreeStyle Libre brand is covered under your 
Plan. 
 
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 Dexcom G7 CGM receiver have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) receiver.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74177 billed for date of 
service January 25, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be covered 
because they are supported in the documentation. The Plan denied your request. The Plan says the radiology 
services are denied because records do not include the actual date of service on which these services were 
performed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. We were able to confirm the procedure note for 74177 does not 
include an actual date of service. Documentation shows an order for 74177 dated January 9, 2023, and a 
procedure note that was electronically signed by the provider on January 25, 2023, but does not document the 
actual date the procedure took place. This is not considered sufficient to verify the date of service. Based on 
this information, we decided that there is insufficient information in the record to determine if Medicare rules 
for coverage of the radiology services have been met. Therefore, we decided that the Plan does not have to pay 
for the radiology services coded as 74177 billed for date of service January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment, coded L4397, billed for date of 
service March 16, 2023. 
 
You asked the Plan to pay for the billed services . You say that the previous item is broken down. The Plan 
denied your request. The Plan says the equipment was reported within the previous 5 years. 
 
The Plan must follow Medicare rules. The rules say equipment which the beneficiary owns or is a capped rental 
item may be replaced in cases of loss or irreparable damage. 
 
The file shows that an ankle-foot orthosis was provided on March 16, 2023. The enrollee previously received 
this item on February 16, 2022. This means that the criteria for the reasonable useful lifetime of the equipment 
have not been met. Furthermore, the provided orthosis is not covered when used solely for the prevention of a 
heel pressure ulcer. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for durable medical equipment, coded L4397, 
billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (64483LT). 
 
You asked the Plan to pre-approve an ESI. The Plan denied your request. The Plan says the request is denied as 
not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using same scale for at least 3 months. 
 
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 ESI. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found the patient has chronic low back 
pain, underwent a transforaminal ESI in June, and had only 40% pain relief 3 weeks later. The request to repeat 
was made before 3 months had passed. Our reviewer also found that the patient did not achieve 50% pain relief 
for 3 months, which is the LCD criteria. 
 
 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (64483LT).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 1, 2022 to 
December 7, 2022. 
 You asked the Plan to pay for home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 1, 2022. The NOA was not received by the Plan until May 25, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on December 1, 2022 to December 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from August 6, 2022, to September 17, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an itemized bill was 
not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. An 
itemized bill was not submitted by the non-contract provider. The records show that the Plan made several 
attempts to obtain an itemized bill. Therefore, we decided that the Plan does not have to pay for the services 
provided from August 6, 2022, to September 17, 2022.