Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 18, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the posterior non-segmental instrumentation of the knee 
(22840). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says  the service is not medically necessary. The Plan says the spinal fusion 
surgery needs to be approved. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested posterior non-segmental instrumentation (22840) is not medically reasonable or 
necessary. However, there is no associated spinal surgery being clearly requested and/or approved. Instrumentation is not supported if the surgery itself is not approved. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested posterior non-segmental instrumentation (22840) is not medically reasonable or 
necessary. Detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery 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. 
Therefore, the requested right total knee arthroplasty is 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the posterior non-segmental instrumentation of the knee (22840).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code C1713 billed for date of service June 27, 2023. 
 
You asked the Plan to pay for code C1713. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that Services with status indicator N are paid under 
the OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. The code at issue in this case, C1713, is assigned status indicator N 
under OPPS, which means this code is packaged and is not separately payable. Based on this information, we decided that Medicare rules for coverage of code C1713 have not been met. Therefore, we decided that the 
Plan does not have to pay for code C1713 billed for date of service June 27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 You asked the Plan to pre-approve Ferumoxytol. You say that the enrollee is intolerant of oral 
supplementation. The Plan denied your request. The Plan says the enrollee has not tried the preferred drugs.  
 
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 Ferumoxytol. Our physician reviewer 
found that the enrollee has iron deficiency anemia. The Plan requires a trial of drug Infed and Venofer before 
they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There 
is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or 
likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leg and foot x-ray provided on June 04, 2023. 
 
You asked the Plan to pay for the leg and foot x-ray. You say that you say that the service was 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 the leg and foot x-ray 
provided on June 04, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, Gel-Syn, for intra-articular 
injection (J7328).  
 You asked the Plan to pre-approve the medication. You say that GELSYN-3 (J7328) is medically necessity for 
the enrollee's treatment for osteoarthritis of the knee.  The Plan denied your request. The Plan says this request 
does not meet the Plan's step therapy criteria for the requested viscosupplement device. 
 
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 the medication. Our reviewer says that 
the Plan's criteria for coverage has not been met. Our physician reviewer found the Plan requires a trial of drug 
Orthovisc or Supartz FX before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan or derivative, Gel-Syn, for intra-articular injection (J7328).
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 was previously independent. You say 
the enrollee meets full medical and functional criteria to qualify for an inpatient acute rehabilitation. The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met 
at a lower level of care such as a skilled nursing facility  
 
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 enrollee has a medical history of hypertension, hyperlipidemia, diabetes mellitus 
type II, coronary artery disease and peripheral vascular disease.  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. The enrollee was admitted to the hospital on November 25, 2023 after 
sustaining a small left acetabular fracture and proximal hamstring tendon injury after falling. The enrollee has 
not had a significant fracture and has not had surgery. There are no significant changes in his neurological 
status or other medical conditions outside of the acetabular and hamstring injury. The enrollee does not require 
the oversight of a rehabilitation physician. The enrollee does not require rehabilitation nursing for complex 
wound care, parenteral nutrition or tube feedings, tracheostomy management or neurogenic bowel and bladder 
management. The enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Precise Tumor 
test (81479) provided on May 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory testing. You say that please reprocess this claim to pay for the test 
as Medicare would have paid. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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. Also, there is insufficient information in the record to determine if Medicare rules for 
coverage of the laboratory testing. The records show that the Plan requested additional records multiple times 
from the provider without success. 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 the unlisted molecular pathology 
procedure, Precise Tumor test (81479) provided on May 23, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
number 20. 
 
You asked the Plan to pre-approve the dental services. You say that if no crown is done further breaking will 
occur and it will be lost. The Plan denied your request. The Plan says services to treat the effects of tooth wear 
are not covered and the primary treatment that has not been approved. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the provided x-rays are over a 
year old and do not show the current condition of tooth number 20. Due to the lack of diagnostic x-rays 
included, a crown (D2740) and core buildup (D2950) for tooth number 20 is not medically necessary.  
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth number 20.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of COVID-19 test, nonprescription self-
administered and self-collected use (K1034) provided June 26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that please, find the attached documents and 
process the claim towards payment. The Plan denied your request. The Plan says Over the Counter (OTC) 
covid tests, K1034, are not covered by Medicare after May 11, 202 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for provision of 
COVID-19 test, nonprescription self-administered and self-collected use (K1034) provided June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691), provided 
on May 4, 2023. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication this item was needed or ordered in the clinical records submitted. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691), provided 
on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia and the injection provided on May 18, 2023. 
 
You asked the Plan to pay for the anesthesia and the injection. 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 anesthesia and the 
injection provided on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen system and the oxygen concentrator 
provided on February 15, 2023, to April 15, 2023. 
 
You asked the Plan to pay for the portable oxygen system and the oxygen concentrator. 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 portable oxygen 
system and the oxygen concentrator provided on February 15, 2023, to April 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided July 17, 2023, billed 
with coded 87481, 87798 x13, 87652, 87500, and 87640.  
 
You asked the Plan to pay for the laboratory testing. You say that the ordering doctor is in-network and 
therefore you are requesting the charges be reconsidered. The Plan denied your request. The Plan says the PCR 
testing is considered unproven and 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 looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel testing 
provided July 17, 2023, billed with coded 87481, 87798 x13, 87652, 87500, and 87640.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing-facility care (99308, 99309, 99315) provided from 
March 6, 2023, to March 16, 2023. 
 
You asked the Plan to pay for nursing-facility care. You say that you have reported the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nursing-facility care have not been met. Specifically, the documentation submitted does not 
identify nor include a valid signature from the persons responsible for the care of the beneficiary. Therefore, we 
decided that the Plan does not have to pay for nursing-facility care (99308, 99309, 99315) provided from 
March 6, 2023, to March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 18, 2023. 
 
You asked the Plan to pay for the home 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 home visit provided 
on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment, free-standing (E0849) 
provided May 1, 2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that please see attached medical 
records. The Plan denied your request. The Plan says the records do not support the billed service.  
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, outreach to the ordering provider indicated, the 
Plan verified with the providers office that the provider did not order this item for this DME item. Outreach to 
the enrollee, the enrollee also denied requesting this item and stated that they keep getting items from this 
supplier that was not ordered, requested or needed. Therefore, we decided that the Plan does not have to pay for 
the cervical traction equipment, free-standing (E0849) provided May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 20, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 urine polymerase chain reaction (PCR) panel testing provided on July 20, 
2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900.