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

 
We decided that the Plan does not have to pre-approve Zejula capsule 100mg. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug and does not fall under Part B coverage. 
 
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 Zejula capsule 100mg.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a lumbar interspinous process 
stabilization device without decompression or fusion (22869). 
 
You asked the Plan to pre-approve the insertion of a lumbar interspinous process stabilization device without 
decompression or fusion (22869). You say that Original Medicare covers this service, and that Medicare does 
not create local coverage determinations (LCD's) for every procedure that is considered by Medicare as a 
covered benefit because specific criteria may not be needed to outline medical necessity. You say that the 
enrollee meets all Food and Drug Administration (FDA) approved indications for the procedure. The Plan 
denied your request. The Plan says is unproven and not medically necessary due to insufficient evidence of 
efficacy. 
 
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 insertion of a lumbar interspinous 
process stabilization device without decompression or fusion (22869). Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found 
interspinous process distraction devices are experimental, and more research is needed. 
 
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 insertion of a lumbar interspinous process stabilization device without 
decompression or fusion (22869) have not been met. Therefore, we decided that the Plan does not have to pre-
approve the insertion of a lumbar interspinous process stabilization device without decompression or fusion 
(22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services rendered on March 15, 2021. 
 
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 this charge is included in APC reimbursement. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services rendered on March 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 
 
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. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There are no pulmonary function tests to confirm airways obstruction and assess severity. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no documentation of chronic 
carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while stable. If that is present, you may 
benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
during sleep as an outpatient.  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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on November 9, 2022. 
 
You asked the Plan to pay for the telehealth services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says you billed the telehealth services in dispute with an 
incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that telehealth services should be billed using either 
Place of Service (POS) code 02 (telehealth provided other than in a patient's home), or 10 (telehealth provided 
in a patient's home). In this case, you billed the telehealth services in dispute with POS code 23 (emergency 
room), instead of one of the required POS codes for telehealth services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth services provided on November 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 1, 2022, 
to September 16, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that after a RAP has been paid and a 60-day episode 
has been completed, or the patient has been discharged, the HHA submits a claim to receive the balance of 
payment due for the episode 
 
We looked at the file and Medicare rules. The file shows that the RAP billed for the claims does not match the units of service that were provided. Therefore, we decided that the Plan does not have to pay for the home 
health services rendered from September 1, 2022, to September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT 648 Gene Panel billed with code 81455 for 
date of service November 17, 2022. 
 
You asked the Plan to pay for code 81455. You say that this testing was ordered by the patient's physician and 
should be covered at the in-network level. The Plan denied your request. The Plan says this testing is not 
covered because this test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that  in order for a Next Generation Sequencing lab 
test to be considered for coverage, the test must be approved by the Food and Drug Administration (FDA).  In 
this case, the specific test at issue does not have FDA approval. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 81455 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Tempus xT 648 Gene Panel billed with code 81455 for date of service November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided from March 1, 2021, to March 15, 
2021. 
 
You asked the Plan to pay for the dialysis services. You say that these services were billed with the required 
value codes in Box 39 of the claim. The Plan denied your request. The Plan says you did not bill the required 
value codes and value amounts needed.  
The Plan must follow Medicare rules. Medicare rules say that ESRD claims must indicate the applicable Kt/V 
reading for the dialysis patient. The reading result and the date of the reading must be reported on the claim 
using Value Code D5. This value code must be accompanied by occurrence code 51.  Renal dialysis facilities 
are required to report hematocrit or hemoglobin levels for their Medicare patients receiving erythropoietin 
products. Hematocrit levels are reported in value code 49 and reflect the most recent reading taken before the 
start of the billing period. Hemoglobin readings before the start of the billing period are reported in value code 
48. 
 
In this case, the only value codes that you billed on the claim were A8, A9, and D5.  You did not bill value 
codes 48, 49.  In addition, you did not bill the required occurrence code of 51 needed with value code D5.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay 
for dialysis services provided from March 1, 2021, to March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the requested power wheelchair and 
accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not 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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that while the 
enrollee may be able to safely operate a PMD, the requested Group 3 power wheelchair with multiple power 
options exceeds the enrollee's medical needs. The enrollee does have a Group 3 qualifying neurologic 
diagnosis, but the documentation does not reveal that the enrollee is at high risk for development of a pressure 
ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. As the requested PWC base is not medically necessary, the requested accessories 
are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that you have lost your lower denture and unable 
to eat. You say you are in a personal home care and cannot pay out-of-pocket for a new denture. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 11, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the complete mandibular denture (D5120).
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 the enrollee needs the skilled care to continue 
making progress. The Plan denied your request. The Plan says the SNF services you are requesting do not meet 
the requirements for approval. 
 
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 skilled nursing 
facility (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 skilled nursing facility (SNF) care.
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 you do not feel ambulatory enough to take care of 
yourself home alone and need more physical therapy. The Plan denied your request. The Plan says that the 
coverage criteria has not been 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 that you do not require daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0482) rendered on 
November 17, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be processed. The Plan denied your 
request. The Plan says the medical records only support 8 drug classes. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, this cod requires 
documentation of 15-21 drug classes test. The records only support 8 drug classes tested. 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 drug testing services (procedure code G0482) rendered on 
November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81002 for November 
30, 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 claim was not billed with a valid CLIA ID. 
 
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order 
to receive reimbursement from Federal programs.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a CLIA ID. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with code 81002 for 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for January 5, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that follow-up services are included in the global surgical 
package 
 
We looked at the file and Medicare rules. Procedure code 99214 was related to and billed within 90 days of 
major surgical procedure billed with code 28010 on November 28, 2022. Payment for code 99214 is included 
in the global surgical package for code 28010. Therefore, we decided that the Plan does not have to pay for 
procedure code 99214 billed for January 5, 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 the member's current medical condition 
requires an LTACH admission and is stable for transfer. The Plan denied your request. The Plan says the 
member does not meet the requirements for an LTACH admission. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care 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 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: Favorable

 
We decided that the Plan has to pay for the anesthesia services rendered on February 22, 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 that anesthesia codes are paid to anesthesia providers only. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that billed anesthesia code 00830 can be paid to an anesthesia 
provider only; however, the file shows that the provider is an Anesthesia Assistant. This provider is able to 
provide anesthesia services per Medicare rules. Therefore, we decided that the Plan has to pay for the 
anesthesia services rendered on February 22, 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 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 plans required drug would likely be less effective 
and/or likely have adverse effects for you. 
 
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.