Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that 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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drug Venofer. Also, there is no documentation indicating that the Plan's required drug 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve D6104. We decided that the Plan does not have to pre-approve 
D6010, D7321, or D4266.  
 You asked the Plan to pre-approve a bone graft at time of implant placement (D6104) for tooth #5 and #14, a 
bone graft at time of implant placement (D6010), an alveoloplasty (D7321), and a guided tissue regeneration 
(D4266). You say that  The Plan says that  
 
We decided that the Plan has to pre-approve D6104 for tooth #5 and #14.  
 
Our medical doctor found that D6104 is medically necessary to ensure proper integration and good long-term 
prognosis for the dental implants in area #'s 5 and 14. Therefore, we decided that the Plan has to pre-approve 
D6104.  
 
We also decided that the Plan does not have to pre-approve D6010, D7321 or D4266. 
 
The benefit limit for D6010 was exhausted on April 17, 2023. D7321 and D4266 are not covered dental 
benefits. Therefore, we decided that the Plan does not have to pre-approve D6010, D7321, or D4266. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose genetic response report and the hereditary 
genetic cardiac test panel provided December 28, 2022. 
 
You asked the Plan to pay for genetic testing. You say that please have a look at the attachment and reconsider 
the charges which were previously denied. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for the tests performed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the enrollee underwent comprehensive hereditary 
pharmacogenomic testing and hereditary genetic cardiac testing. There is no documentation from the provider 
documenting the drugs being considered for use and no documentation to how the results will impact treatment.  
The review has determined that the items/services at issue in this case were not medically reasonable or 
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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneDose genetic response report and the hereditary genetic cardiac test panel provided 
December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305, 88307, 88342, and 88341 billed for 
date of service December 14, 2022. 
 You asked the Plan to pay for procedure code(s) 88305, 88307, 88342, and 88341. The Plan denied your 
request. The Plan says these codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305, 88307, 88342, 
and 88341. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305, 
88307, 88342, and 88341. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88305, 88307, 88342, and 88341 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88305, 88307, 88342, and 88341 billed for date of service December 14, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on September 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for these 
services is included in the facility payment. 
 
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 payment for these services is included in the facility 
payment. However, the Plan has not provided documentation showing payment made to the facility for services 
rendered. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the services provided on September 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a CGM. You say that a new CGM would take less time to test. The Plan denied 
your request. The Plan says the current CGM has not exceeded its reasonable useful lifetime (generally 5 years) 
is not irreparably damaged or worn and is not malfunctioning. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pay for a Dexcom 
G7 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that policy requires payment for certain outpatient 
services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 
calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) 
with the Medicare Part A payment for the beneficiary's inpatient admission if those outpatient services are provided by the admitting hospital or an entity that is wholly owned or wholly operated by the admitting 
hospital.  
 
We looked at the file and Medicare rules. The services in question fall within the payment window for 
outpatient services treated as inpatient services. Payment for the requested services is included in the payment 
for the Part A claim. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on April 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from February 18, 
2022, to April 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychotherapy services. You say that this is a Medicare provider. You say 
that this provider has not been paid for services from 2022 to 2023. You say that you have contacted your plan 
regarding these many times. You say that you were advised to get a letter from your primary care physician 
(PCP). You also say that you were advised the services would be paid. The Plan denied your request. The Plan 
says prior authorization was not obtained. The Plan also says the services were not urgent or emergent. 
 
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 in this case is not a network provider with the Plan. 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 psychotherapy services provided from February 18, 2022, to 
April 13, 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 an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you have intense pain in your 
lower back, and you have regularly received these injections in the past. You say that you are unable to walk or 
function without the injections as you suffer from intense back pain caused by sciatica. The Plan denied your 
request. The Plan says your records show that the requested service exceeds the limits. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that according to the coverage criteria, limitations on epidural steroid injections 
state that ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month 
period. In this case, you have exceeded the limit for injections during the past rolling twelve (12) month period. 
The review has determined that the requested epidural steroid injections do not meet the Medicare LCD 
coverage 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2022, to May 
30, 2022. 
 You asked the Plan to pay for the home health services. You say that you have sent in the NOA. The Plan 
denied your request. The Plan says the NOA has not been received. 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 Plan has confirmed that it has not received the required NOA from you. As a result, 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 1, 2022, to May 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (20930). 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this device is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided January 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration of the denial of 
coverage and payment for PrismRA testing. The Plan denied your request. The Plan says this PrismRA test is 
not a covered test.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. This test is not FDA approved and based on the diagnostic program, 
MolDX Technical Assessment, the PrismRA test is not an approved test. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the PrismRA testing (81479) provided January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99213) rendered on February 
8, 2023. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT 99213 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that there was no evidence of low-level 
decision making, or documentation of 20-29 minutes of total time spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99213) rendered on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on December 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152-59 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of CPT 99152 to be billed separately from CPT 45385. Another code would have been more 
appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on December 9, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient home or residence visit (99350) 
provided on February 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home or residence visit. You say that please review the attached medic 
records proving medical necessity and reprocess this claim for payment. 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 established patient home or residence visit 
(99350) provided on February 2, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for outpatient services provided on November 10, 2022. 
 
You asked the Plan to reduce the copayment for outpatient services. You say that you should only be liable for 
a $20 copayment. The Plan denied your request. The Plan says that the cost-share was applied correctly. 
 
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 did not provide any documentation or medical records to confirm the 
services received on November 10, 2022. Without this information we are unable to determine if the cost share 
amount was applied correctly. Therefore, we decided that the Plan has to reduce the copayment for outpatient 
services provided on November 10, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation (A0080, S0215) provided on 
January 15, 2023. 
 
You asked the Plan to pay for non-emergency transportation. You say that this was more cost-effective form of 
transportation than an ambulance. The Plan denied your request. The Plan says this service is not covered. 
 The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transportation have not been met. Furthermore, we find 
that procedure code S0215 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure 
code S0215 is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for 
non-emergency transportation (A0080, S0215) provided on January 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the laboratory services coded as 88305 and 88312 provided 
December 21, 2022. 
 
You asked the Plan to pay for  the laboratory services. You say that you are asking for reconsideration of the 
out of network deductible that was applied to this claim. 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. Your 
contract with the Plan says that there is 40% coinsurance for each freestanding laboratory visit after the $750 
combined deductible.  
 
The item or service you asked the Plan to pay for falls within the Laboratory service benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 combined deductible which applies to Laboratory service. This cost sharing is a contractual obligation that had not been met at the 
time the laboratory services was received on December 21, 2022. Therefore, we decided that the Plan does not 
have to pay for  the laboratory services coded as 88305 and 88312 provided December 21, 2022.