Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on February 22, 2023, to March 15, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the water circulating heat pad with pump. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. 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. 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 water circulating heat pad with pump (E0217) 
provided on February 22, 2023, to March 15, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiotherapy (SBRT) (77370, 
77373). 
 
You asked the Plan to pre-approve SBRT. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says there is evidence that this type of 
radiation is not needed and not effective for the enrollee's cancer. Therefore, it not considered standard of care. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for this enrollee, there are 4 sites of metastases as well as residual/recurrent axillary disease. 
She just started systemic therapy. Notably, this enrollee has no pain in the bony sites (per the radiation 
oncology notes) and has nodal recurrence of breast cancer (that is causing pain being managed medically). 
Given recent data showing no benefit of SBRT for enrollees with oligometastatic breast cancer (and the 
inherent risks associated with such treatment  including bone fracture) routine use of SBRT would not be 
considered to be furnished in accordance with accepted standards of medical practice. As such, the decision is 
unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiotherapy (SBRT) (77370, 77373).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 1, 2023. 
 
You asked the Plan to pay for the billed testing.. You say that the test is a Medicare covered benefit. The Plan 
denied your request. The Plan says the test is non-covered. 
 
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. The test was assessed, and it was determined that the reasonable and 
necessary requirements have not been met. Based on this information, we decided that Medicare rules for 
coverage of the billed testing. have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing billed for date of service May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 24, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on August 24, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of a drug like 
Lucentis before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. Our physician reviewer also found that there is no documentation indicating that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the patient. 
 
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 (J0178).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient surgery provided on July 
17, 2023, to August 03, 2023. 
 
You asked the Plan to waive the copayment for each outpatient surgery. You say that the copayment applied to 
each claim is over exaggerated billing. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $295 copayment for each outpatient surgery. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 total you owe is $590 ($295 copayment x 2 visits = $590). Therefore, we decided that the Plan does not 
have to waive the copayment for each outpatient surgery provided on July 17, 2023, to August 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for swallow testing provided on June 26, 2023. 
 
You asked the Plan to pay for swallow testing. You say that this patient was treated in good faith, please pay 
the provider. 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 swallow testing 
provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81345) provided on October 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this service is not 
payable with the billed modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines are not payable when billed with 
modifier GZ. 
 
We looked at the file and Medicare rules. In this case, code 81345 was billed with modifier GZ, which is not 
payable per Medicre rules. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
(81345) provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 31, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are 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 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 home visit provided on March 31, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth consultation, emergency department or initial 
inpatient (G0426) provided on July 29, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth visit. You say that the enrollee was in a nursing home at the time 
services were rendered. Since your company has an exclusive contract with the facility, your doctors are the 
only providers who will treat the patients. 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. 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 telehealth consultation, emergency department 
or initial inpatient (G0426) provided on July 29, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0848). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair. You say that this is medically 
necessary because you cannot walk. The Plan denied your request. The Plan says the requested power 
wheelchair is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with no power 
options (such as code K0848) is covered if the criteria listed in the Medicare rules section of this letter are met.  
 
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 Group 3 standard power wheelchair. 
Our reviewer says that the requested Group 3 power wheelchair is not medically necessary. Our physician 
reviewer found the clinical documentation is insufficient why a lower-level power wheelchair would not meet 
your needs versus a Group 3 power wheelchair. There is inadequate clinical documentation regarding why you 
would require power tilt and recline and cannot adequately perform pressure relief. There is no history of skin 
breakdown and sensation is intact. Our reviewer found that there is no significant lower extremity spasticity 
that would necessitate a power elevating foot platform. A Group 3 power wheelchair base is typically indicated 
in patients with significant paralysis due to conditions such as a spinal cord injury or multiple sclerosis. Our 
physician reviewer also found that a power wheelchair is not indicated on what your condition may necessitate 
in the future, but rather your current mobility and functional needs. 
 
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 Group 3 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0848).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the requested bed is not covered; the height adjustment feature is a 
convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 06, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were 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 psychotherapy provided 
on September 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on May 
2, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered was not covered. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on May 2, 2023, to May 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that on October 26, 2023, the Food and Drug 
Administration (FDA) approved Vabysmo for the treatment of macular edema following retinal vein occlusion 
(RVO). You also say that RVO is the third indication approved for Vabysmo. The Plan denied your request. 
The Plan says this request is not medically necessary. 
 
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 Vabysmo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of a Eylea, 
Byooviz, and Cimer before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. Our reviewer also found that there is no documentation indicating that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87486, 87541, 87581, 87631, 87636, 87640, 
87651, 87653 and 87798) provided on May 1, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
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. We find that the services at issue were actually rendered/performed in a state 
which is not under the jurisdiction of the Local Coverage Determination/Article cited by the Plan. The state in 
question does not participate in the Molecular Diagnostics (MolDX) contractor program, and therefore MolDX 
rules do not apply. This means that the requirement of a Dex-Z code does not apply in this case, and the Plan 
has not substantiated their denial. Therefore, we decided that the Plan has to pay for laboratory services (87486, 
87541, 87581, 87631, 87636, 87640, 87651, 87653 and 87798) provided on May 1, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on September 6, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
September 6, 2023.