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

 
We decided that the Plan does not have to pay for a comprehensive PGX panel and comprehensive hereditary 
genetic testing billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, and 81579 for date of service January 10, 2023.   
You asked the Plan to pay for the comprehensive PGX panel and comprehensive hereditary genetic testing. 
You say that the records provided support the services in dispute.  The Plan denied your request. The Plan says 
the denial of the services in dispute was appropriate given the clinical scenario and Medicare guidance.  
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenetics testing will be considered 
medically reasonable and necessary if the patient has a condition where clinical evaluation has determined the 
need for a medication that has a known gene-drug interaction(s) for which the test results would directly impact 
the drug management of the patients condition. 
 
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 comprehensive PGX panel and 
comprehensive hereditary genetic testing. Our reviewer says that the criteria for coverage have not been met. 
Our physician reviewer found the enrollee has a diagnosis of Essential (primary) hypertension, as well as 
hypercholesterolemia and obesity. The limited documentation does not support that the enrollee has a condition 
where clinical evaluation has determined the need for a medication that has a known gene-drug interaction(s) 
for which the test results would directly impact the drug management of the patient's condition.  
 
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 comprehensive PGX panel and comprehensive hereditary genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive PGX panel 
and comprehensive hereditary genetic testing billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81335, and 81579 for date of service January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rybelsus. 
 
You asked the Plan to pre-approve Rybelsus. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rybelsus.  Benefits for Rybelsus may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 11, 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 services are medically necessary due to the 
enrollee's complex medical issues so that they can achieve maximal optimization. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the inpatient hospital stay provided by an in-network 
provider from December 30, 2022, to January 4, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you think that the 
copayment is too high. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $325 copayment per day for days 1 through 5 for in-
network covered hospital care in 2022, and a $260 copayment per day for days 1 through 5 for in-network 
covered hospital care in 2023.  
 
The Plan says you must pay a $1625 copayment for the inpatient hospital stay ($325 x 5 days = $1625). Based 
on the Plan contract, however, you cannot be asked to pay more than a $260 copayment per day in 2023 for the 
inpatient hospital stay. This means that you are responsible for a $1430 copayment for the inpatient hospital 
stay ($325 copayment x 2 days = $650) ($260 copayment x 3 days = $780) ($650 + $780 = $1430 copayment). 
Therefore, we decided that the Plan has to reduce the copayment for the inpatient hospital stay provided by an 
in-network provider from December 30, 2022, to January 4, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
March 17, 2023, to March 20, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found you have a history of bladder and prostate cancer status post-surgery and 
nephrostomy tube placement and you presented to the emergency department (ED) with right flank pain for ten 
days with no urine drainage from right nephrostomy tube. Your vitals were stable except for elevated blood 
pressure. There were no signs/symptoms of infection. The x-ray showed dislodged nephrostomy tube with 
hydronephrosis. The plan included urology consultation for nephrostomy replacement. Based on your stability 
and only requiring one procedure without expectation of complication or prolonged aftercare, it was not likely 
you would have required a 2-midnight hospital stay at the time of admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 17, 2023, to  
March 20, 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 requires extensive therapy and daily 
physician management to optimize their mobility. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an IRF.  
 
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 does not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 30-39 minute follow-up visit (99214). 
 
You asked the Plan to pre-approve a 30-39 minute follow-up visit. 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 30-39 minute follow-up visit. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the visit was approved for the enrollee, but the code associated with it, 
99214 for this 20-min very low complexity visit is not sufficiently supported in the documentation for this date 
which didn't include a physical exam. The code, 99212, would be more appropriate for this appointment according to the documentation provided. Therefore, although the visit is medically reasonable, this request for 
associated 99214 code is not appropriate.  
 
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 30-39 minute follow-up visit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a 30-39 minute follow-up visit (99214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you already had a steroid injection 
in your spine and that did not help. You say that your physician located the area of the pain and determined that 
you need the radiofrequency ablation. The Plan denied your request. The Plan says the radiofrequency ablation 
is 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 pre-approve the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the radiofrequency ablation is considered an experimental procedure because of the wide variation in efficacy 
reported in the literature.   
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits (99213 and 99214) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the medical services are available to be provided by an 
in-network provider. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the enrollee 
should be able to safely and effectively be able to receive the same services by a qualified in-network provider 
which has been made available by the Plan. There were no unique clinical circumstances or special treatments 
needed by the enrollee that only the requested provider could provide that are not available via an in-network 
board-certified oncologist. Therefore, this request for office visits via an out-of-network physician will be 
considered not medically necessary at this time.  
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office visits (99213 and 99214) to be provided by an out-of-
network provider.
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 you are requesting reconsideration for 
the denial of an LTACH admission. 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 you are improving but still require acute care services before transitioning to a 
lower level of care. You continue to receive acute care services, and these have not been denied by the Plan. 
The medical record does not indicate that you require services that you are not currently receiving but that 
would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99203, 99213x5) with a specialist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you have been having complications from 
bariatric surgery in 2005 and you have been unable to locate an in-network surgeon who will see you. The Plan 
denied your request. The Plan says you must use network providers to get health care and services when there 
are network providers available. 
 
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 
office visits (99203, 99213x5) with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultomiris.  
You asked the Plan to pre-approve Ultomiris. You say that Ultomiris is medically necessary. The Plan denied 
your request. The Plan says a trial of at least 2 immunosuppressants is required before alternative treatments 
can be considered. 
 
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 Ultomiris. Our reviewer says that 
Ultomiris is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred treatments, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ultomiris have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ultomiris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on March 15, 2023, billed with 
evaluation and management (EM) code 99222-AI. 
 
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 this claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. This claim was inappropriately billed with 
POS 21, as the documentation shows that the patient was in outpatient observation on this date of service. 
Therefore, we decided that the Plan does not have to pay for Practitioner services provided on March 15, 2023, 
billed with evaluation and management (EM) code 99222-AI.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 6, 2022, to May 5, 
2022. 
 You asked the Plan to pay for the home health services. You say that the Plan did not provide a definitive 
reason for its denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 6, 2022. The NOA was not received by the Plan until May 16, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 6, 2022, to May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
September 2, 2022, to September 22, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also 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 a pneumatic compression device (E0675) provided September 2, 2022, to September 22, 2022.