Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for fixed wing air mileage (A0435) and fixed wing air transport (A0430) 
provided on May 21, 2023. 
 
You asked the Plan to pay for fixed wing air mileage (A0435) and fixed wing air transport (A0430). You say 
that the services were medically necessary and reasonable due to the critical emergency the member was 
experiencing that required immediate intervention. The Plan denied your request. The Plan says that the 
received services not medically reasonable and necessary.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 fixed wing air mileage (A0435) and fixed 
wing air transport (A0430). Our reviewer says that transfer by air-ambulance to provide necessary services and 
decrease out-of-hospital time was medically necessary and reasonable. Our physician reviewer found the 
enrollee, being treated for pneumonia and a urinary tract infection (UTI), developed sepsis requiring intensive 
care unit (ICU) management and vasopressor support. Our physician reviewer also found the imaging shows a 
possible renal abscess and common bile duct stone, for which additional services were required. At the time of 
the transfer, the enrollee was on low-dose vasopressors, just had received an albumin infusion, blood pressure 
was low, and transfer by ground would have taken several hours. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fixed wing air mileage (A0435) and fixed wing air transport (A0430) have been 
met. Therefore, we decided that the Plan has to pay for fixed wing air mileage (A0435) and fixed wing air 
transport (A0430) provided on May 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an expanded pathogen panel (87481, 87640, 87651, 87653, 
87798) provided on July 10, 2023. 
 
You asked the Plan to pay for an expanded pathogen panel. You say that this was medically necessary. The 
Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that expanded (more than 5 pathogens) panels must 
either be billed with places of service (POS) 19, 21, 22, 23, or be ordered by an Infectious Disease Specialist, 
Oncologist, Transplant specialist, Pulmonologist, or Gastroenterologist. 
 
We looked at the file and Medicare rules. The services at issue were billed with POS 81 and were not ordered 
by an Infectious Disease Specialist, Oncologist, Transplant specialist, Pulmonologist, or Gastroenterologist. 
Based on this information, we decided that Medicare rules for coverage of an expanded pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for an expanded pathogen panel (87481, 
87640, 87651, 87653, 87798) provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 July 6, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on July 31, 2023, billed with evaluation 
and management code 99205-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the level of care is not supported. 
 
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 99205-25 is office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. 
 
We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the enrollee's visit notes indicate a 
complete history, physical exam and interpretation of labs and other studies. Her presentation included 
symptoms that suggested a possible risk of stroke, which requires a high level of medical decision making and 
degree of complexity which meets criteria for the requested code. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on July 31, 2023, billed with evaluation and management 
code 99205-25.  
 
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 Altru Dx urinary tract infection panel (87798) provided June 
1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR 
(polymerase chain reaction) panel testing is considered excessive testing 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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with dysuria underwent urinary testing. The enrollee underwent 
urinalysis, however, there was no indication for the PCR testing as the urinalysis and culture should have been 
sufficient to test this enrollee as that is the standard of care. There was no explanation found in the 
documentation for the PCR testing being important in the care of this enrollee, nor is there current literature 
showing high quality evidence to support regular use of PCR testing instead of urinalysis and culture for 
similar cases. Therefore, this request for Altru Dx urinary tract infection panel will be considered not medically 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for Altru Dx urinary tract infection panel (87798) provided June 1, 2022.
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's medical complexity requires physician 
oversight, frequent monitoring and intervention through physician face to face visits at least three times per 
week. You say that the enrollee is expected to actively participate in three hours of therapy 5 days per week. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Durolane, Monovisc, or Synvisc-One. The records do not 
support that the required drugs would be contraindicated or less effective; therefore, Gel-One is not reasonable 
or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-One.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that the enrollee has 7 compression fractures. The Plan 
denied your request. The Plan says the enrollee has not tried the preferred product.  
 
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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of drug Forteo before they will approve the 
requested drug. In this case, the enrollee has 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 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 You asked the Plan to pre-approve Supartz FX. You say that this is crucial for the enrollee's pain relief and 
increased mobility. You say that the inability to trial the formulary medications should not be a barrier to 
accessing the most appropriate and effective treatment. You also say that the formulary medications are not 
stocked or billed by the office. The Plan denied your request. The Plan says the enrollee has not tried and failed 
the preferred drugs, Monovisc, Orthovisc, Synvisc, Synvisc One. 
 
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 Supartz FX. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer also found that the record does 
not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
drugs. Therefore, the reviewer found that the step therapy criteria have 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
from March 16, 2023, to April 6, 2023, by an OON provider.  
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you are appealing the 
denial with supporting documentation. The Plan denied your request. The Plan says this item is not a covered 
benefit. 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. Medicare rules also say that a fluid circulating cold pad with 
pump (E0218) will be denied as not reasonable and necessary. 
 
The requested provider in this case is not a network provider with the Plan. Per Medicare, a fluid circulating 
cold pad with pump is not covered. Therefore, we decided that the Plan does not have to pay for the fluid 
circulating cold pad with pump (E0218) provided from March 16, 2023, to April 6, 2023, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on July 21, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy. You say that the services rendered on July 21, 2023, should 
be paid for. The Plan denied your request. The Plan says the services should have been provided in network as 
there was not a medical necessity for the services out of network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on July 21, 
2023, by an out-of-network (OON) provider.
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 without an IRF admission the enrollee's health will 
quickly decline. The Plan denied your request. The Plan says the request is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 72072 performed on June 6, 
2023. 
 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 the documentation does not support that the excess units were provided, and also the provider 
has not documented any medically necessary reason for performing extra units. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 72072 is "Radiologic examination, spine; thoracic, 3 
views." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the duplicate report of the same 
exam - CPT 72072 is in the records. Thus only one unit is supported for billing. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 72072 performed on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure (30117, 30801, 30469). 
 
You asked the Plan to pre-approve a VivAer procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been 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 pre-approve a VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient literature to support the safety and efficacy of the requested 
service for the enrollee's specific conditions. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 a VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure (30117, 30801, 30469).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 TissueNext (0362U) provided January 27, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that Guardant360 is a Medicare approved biomarker 
test for all solid cancers that did not originate from the central nervous system through LCD L38043. The Plan 
denied your request. The Plan says this test is considered experimental investigational or unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document the enrollee is diagnosed with metastatic squamous 
cell carcinoma of the lung.  Although provided records document the diagnosis of an advanced solid tumor, the 
provided records do not include adequate detail showing the other required elements for coverage are met 
under the Local Coverage Determination (LCD) MolDX: Plasma-Based Genomic Profiling in Solid Tumors 
L38168. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant360 TissueNext (0362U) provided January 27, 2023.