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

 
We decided that the Plan does not have to pay for laboratory services denoted by codes 88305, 88307, 88341 
and 88342, provided on September 28, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you have billed 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 payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the services at issue all have a 
professional/technical component indicator of 1, meaning that these codes have a professional and a technical 
component. These codes have not been billed with the appropriate modifier to indicate that they are for the 
professional component. Payment for the technical component of these codes is included in the payment to the 
facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have 
to pay for laboratory services denoted by codes 88305, 88307, 88341 and 88342, provided on September 28, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on 
November 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on November 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found treatment with Opdivo and Yervoy for 
stage IV malignant neoplasm of the right lung with prior trial and failure of several chemotherapy regimens 
including pembrolizumab is not approved by the Food and Drug Administration (FDA). The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 
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 Opdivo and Yervoy.
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 you need the inpatient rehab to regain strength to 
return to baseline level of functioning. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/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 imaging services provided on October 31, 2022, billed with 
codes 70496, 70498 and Q9967. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis was invalid as reported. 
 
The Plan follows Medicare rules. Medicare rules say that the reason for the encounter should be billed as the 
primary diagnosis code and the appropriate family history code should be assigned as additional diagnosis.  
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 imaging services provided have not been met. The claim was billed with 
Z82.3 as the principal diagnosis, which is a family history code. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on October 31, 2022, billed with codes 70496, 70498 and Q9967.
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 enrollee would benefit from and 
improve with LTACH services. The Plan denied your request. The Plan says the LTACH services requested do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail intra-articular steroids and simple analgesics 
first. 
 
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 Zilretta. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee.  The requested medication is a new start.  The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative.  The elements of the coverage criteria are not satisfied.  The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair 
received by you on September 24, 2020. The requested replacement is for an item that has not outlasted its 
reasonable useful lifetime. The records do not show that your current device is in disrepair or unable to meet 
your medical needs. Based on this information, we decided that Medicare rules for coverage of a replacement 
power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
replacement power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) ophthalmologist. 
 
You asked the Plan to pre-approve the OON ophthalmologist office visit. You say that you need glasses to 
retain what is left of your vision, as you are nearly blind. You say that every network facility you have been 
referred to has advised you that they do not provide low vision glasses. You say that you need these glasses as 
vision is important to you and you have no one to help you.  The Plan denied your request. The Plan says they 
have confirmed that there are network providers who can provider a low vision aid.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) ophthalmologist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Orthovisc (J7324). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 medication. Our physician reviewer 
found as summarized in the Medicare-approved major drug compendia, Orthovisc is indicated for the treatment 
of pain in osteoarthritis of the knee when response to conservative nonpharmacologic therapy and simple 
analgesics (e.g., acetaminophen) has been inadequate. Provided medical records in this case do not document 
trial and failure of conservative nonpharmacologic therapy. 
 
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 the Orthovisc (J7324).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on June 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided on 
June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital services provided on March 30, 
2023. 
 
You asked the Plan to waive the copayment for the hospital services. You say that you should only have a $30 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the hospital services. This item/service falls within the in-
network outpatient hospital 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. The record shows for this service you are being charged for the use of the 
facility. However, since the allowed amount is less than the standard copayment, you only owe $64.48. 
Therefore, we decided that the Plan does not have to waive the copayment for the hospital services provided on 
March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy to return home to care for 
her husband. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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 Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Synvisc/Synvisc One OR Euflexxa first. 
 
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 Durolane. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of knee.  The requested medication is a new start.  The provided record indicates that 
the provider has changed the prescription to a preferred agent. The provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative.  
The elements of the coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy (NPWT) Pump. 
 
You asked the Plan to pre-approve a Negative Pressure Wound Therapy (NPWT) Pump. You say that the 
requested NPWT Pump is medically necessary.  The Plan denied your request. The Plan says the enrollee does 
not meet criteria for a NPWT Pump. 
 
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 Negative Pressure Wound Therapy 
(NPWT) Pump. Our reviewer says that the enrollee does not meet criteria for a NPWT Pump. Our physician 
reviewer found the enrollee is with a large stage 4 wound on the foot that was treated with wound debridement 
and a wound VAC for 4+ months. Continued use of a Negative Pressure Wound Therapy (NPWT) Pump 
(wound VAC) was requested. Recent notes describe the right leg wound as 3 x 2.5 x 2.7 cm on April 17, 2023, 
and 3 x 2.5 x 2.6 cm (19.5 cm3) on May 15, 2023. Although the provided documentation appears to show a 
very gradual improvement over the last month of wound care including wound VAC use, the records show the 
enrollee has used this device for more than 4 months which means they have exceeded the allowed duration of 
use based on 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 a Negative Pressure Wound Therapy (NPWT) Pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy 
(NPWT) Pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional months (for a total of 12 months) of use of 
a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator 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. 
 
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 reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease (COPD). The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability, and failure of such a device has not been documented. 
 
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 9 additional months (for a total of 12 months) of use of a home ventilator (E0466).