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

 
We decided that the Plan has to pay for the drug testing (80307, G0782) provided on March 13, 2023, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered because it was provided OON. 
 
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. The Plan argues that the requested services are not covered when provided by an 
out-of-network provider. However, the enrollee in this case has a PPO plan. As such, the Plan's contract 
indicates that payment can be made to non-contract providers for covered services. The Plan has not provided 
documentation substantiating its denial. Therefore, we decided that the Plan has to pay for the drug testing 
(80307, G0782) provided on March 13, 2023, by an out-of-network (OON) provider.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hemodialysis services provided from January 3, 2023, to January 
30, 2023. 
 
You asked the Plan to pay for the hemodialysis services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan has not provided enough evidence to support their denial of 
payment for the hemodialysis services based on Medicare criteria. The Plan denied payment for these services 
due to a modifier not being appropriate. However, the Plan has provided no explanation as to why the 
modifiers are inappropriate or what modifiers should have been used in their place. It is the burden of the Plan 
to support their case. Therefore, we decided that the Plan has to pay for the hemodialysis services provided 
from January 3, 2023, to January 30, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the somatosensory testing (95938) and central motor evoked potential 
study (95939) provided on September 12, 2022.  
 
You asked the Plan to pay for the service. You say that these services meet the medical necessity guidelines, 
and you would like a reconsideration of the initial denial. The Plan denied your request. The Plan says that this 
service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or 
National Coverage Determination (NCD). The Plan also says that related services performed in connection 
with the denied procedure are not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this request is medically necessary to help prevent further injury. Due to the increased risk 
associated with this procedure, the item/services at issue in this case are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pay for 
the somatosensory testing (95938) and central motor evoked potential study (95939) provided on September 
12, 2022.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office vistis (99204 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 you have low back pain, you had 
back surgery two years ago, you were told you would need to have it again in two to three years, your original 
surgeon is retiring, and they referred you to this specialist. The Plan denied your request. The Plan says they 
were not provided with a referral and/or clinical information to support your request. The Plan states they 
contacted your primary care physician (PCP) who advised that you have already had a previous back surgery 
and does not consider another surgery appropriate due to your multiple health conditions. 
 
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 
the office vistis (99204 and 99214) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 54 miles for a total of 104 miles. 
 
You asked the Plan to pre-approve the additional mileage. You say that you need to have additional miles due 
to this doctor being the only specialist in the area that can do this. The Plan denied your request. The Plan says 
your request for additional Saferide mileage is not approved. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Your benefit only allows 50 miles, 104 
extra miles would exceed your benefit limit.  Therefore, we decided that the Plan does not have to pre-approve 
an additional 54 miles for a total of 104 miles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the CardioMEMS device at this point should only be approved for patients 
enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a clinical trial of 
the device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
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 an expedited appeal 
for the denial of an LTACH admission. You say discharging the enrollee to an LTACH will help prevent them 
from developing further hospital acquired complications and improve their overall functional status. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for care in an LTACH.  
 
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 documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. 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 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: 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 are requesting authorization to complete 
interrupted inpatient rehabilitation services. You say the enrollee has now stabilized and is ready to return to 
the IRF to complete needed intensive therapy. The Plan denied your request. The Plan says the enrollee does 
not meet the guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report provided on 
November 30, 2022. 
 You asked the Plan to pay for the GeneDose Genetic Response Report. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the GeneDose Genetic Response Report, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the GeneDose Genetic Response Report provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you are requesting additional trips beyond 
what your yearly allowed trips are. The Plan denied your request. The Plan says the request exceeds the benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at your request, the records in the case file, and the rules. The 21st trip and beyond is not a covered 
benefit. Your 2023 EOC states, (20) one-way trips to Plan-approved locations every year, provided by the 
network transportation provider. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional one-way transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare. 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 October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of device. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use with very low set tidal volumes (150 milliliters (mL) to 200 
mL) which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (AVAPS) mode and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac injection (27096). 
 
You asked the Plan to pre-approve sacroiliac injection. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 sacroiliac injection. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the request meets all of the coverage criteria and is medically reasonable and 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 sacroiliac injection have been met. Therefore, we decided that the Plan has to 
pre-approve sacroiliac injection (27096).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 23, 2022, 
through July 13, 2022.  
 You asked the Plan to pay for the home health services. You say that the records support that payment should 
be made. 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 June 23, 2022. The NOA was not received by the Plan until July 26, 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 the home health services provided from 
June 23, 2022, through July 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the request was previously approved, but the wrong 
address was used. The Plan denied your request. The Plan says the step therapy requirements have not been 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that there is no indication that the enrollee has tried and 
failed the Plan's required drugs ibandronate, pamidronate, or zoledronic acid. Also, there is no indication that 
the Plan's required drugs would likely be less effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease or foraminal stenosis. The cause 
of the enrollee's pain is not clear. The Intracept procedure is therefore 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 an Intracept procedure.