Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 14, 2022, to 
January 26, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the 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 January 14, 2022. The NOA was not received by the Plan until April 8, 
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 
rendered from January 14, 2022, to January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone identified with procedure 
code G2078 for date of service November 28, 2022. 
 
You asked the Plan to pay for the take home supply of methadone. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that opioid treatment program services can only be 
billed by facilities. 
 
 We looked at the file and Medicare rules. Review of the file shows that this claim was billed by a provider and 
not the opioid treatment program facility. Based on this information, we decided that Medicare rules for 
coverage of the take home supply of methadone have not been met. Therefore, we decided that the Plan does 
not have to pay for the take home supply of methadone identified with procedure code G2078 for date of 
service November 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the observation care discharge day management provided on November 
30, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says that out-of-network services are not covered. 
 
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. Specifically, the services in this case do not require authorization. Therefore, we 
decided that the Plan has to pay for the observation care discharge day management provided on November 30, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
December 15, 2022.
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 the enrollee has not had any 
previous injections. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
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 the enrollee has chronic low back pain. The enrollee has used heat/ice, 
Mobic, Tylenol, and muscle relaxants. The enrollee has had physical therapy. The enrollee had an epidural 
steroid injection but there is no documentation as to the degree and duration of pain relief from that injection. 
The request does not meet the Medicare LCD coverage criteria due to lack of documentation. The Medicare 
LCD coverage criteria is at least 50% pain relief for three (3) months. At this point, the request is deemed not 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), any joint of upper 
extremity; without contrast material (73221). 
 
You asked the Plan to pre-approve an MRI of the joint. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the joint. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a history of CAD, 
HTN, TIA, HLD, and anxiety and was evaluated for abdominal pain. There is nothing in the medical record 
referencing signs or symptoms of an arm (wrist, elbow, or shoulder) problem. On appeal review, per health 
plan policy guidelines, advanced imaging of the arm is approved after failure of conservative therapy. There is 
no information indicating that there is a problem with the enrollees arm, let alone a failure of conservative 
therapy. The review has determined that the requested MRI is 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 an MRI of the joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI), any joint of upper extremity; without contrast 
material (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits for external counterpulsation and 
pulmonary stress testing (G0166, 99205, 99214, 94618, 99212, 99213, 99215) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this service is available by a provider in your network. 
 
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 for external counterpulsation and pulmonary stress testing (G0166, 99205, 99214, 94618, 99212, 
99213, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on December 6, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary and appropriate. 
The Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 16, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the laboratory testing services are experimental. 
 
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 the laboratory testing. Our reviewer says that 
the requested laboratory testing is not considered medically reasonable and necessary. Our physician reviewer 
found the enrollee is an 88-year-old female with a wound. The laboratory services, genetic testing for wound swab, were rendered on July 16, 2022. However, there was no clinical support provided describing why 
standard testing methods were not appropriate for this enrollee or how genetic testing would lead to superior 
outcomes over standard testing or no testing. Therefore, without sufficient support made, this request for 
laboratory services will be considered not 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 the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on July 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider on March 8, 2023 and confirmed that the Explanation of Benefits (EOB) submitted to them by the 
primary insurer. The Plan has not received an EOB from the primary insurer to process the claim.. As the 
secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on February 23, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transport rendered on November 21, 2022. 
 
You asked the Plan to pay for these services. You say that the enrollee was not under inpatient status. The Plan 
denied your request. The Plan says that payment is included in the inpatient hospital 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 states that the transport is included in the inpatient hospital payment; 
however, the records show that the enrollee was discharged from the hospital on November 21, 2022 at 6:19 
PM, prior to the ambulance departure at 6:22 PM. The Plan has not provided any documentation or binding 
Medicare rules to support that the services are not payable as billed. Therefore, we decided that the Plan has to 
pay for the ambulance transport rendered on November 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 22, 2021, billed with 
codes 81286, 81404, 81405, 81406, 81407, 81439, 81161, and 81043. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not a covered cardiovascular disease screening. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 22, 2021, billed with codes 81286, 81404, 81405, 81406, 81407, 81439, 81161, and 81043.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Juvederm (J3490). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says this drug used for dysphoria and paralysis of the vocals cord and larynx, 
unilateral is not supported by compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Juvederm is not Food and Drug Administration-approved for the enrollee's diagnosis 
of dysphonia and paralysis of the vocals cord and larynx. The requested use of Juvederm for the enrollee's 
diagnosis of dysphonia and paralysis of the vocals cord and larynx is not supported by one of the major drug 
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Juvederm (J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 6, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta 32MG vial (J3490). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found Zilretta 32MG vial is FDA-approved for the enrollee's diagnosis of osteoarthritis of the knee. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this enrollee, however the Plan requires a trial of immediate release triamcinolone injection before they will 
approve the requested drug, Zilretta. Based on the medical records provided there is no indication that the 
enrollee has tried and failed the required drug(s). Based on the medical records provided and the Medicare-
approved major drug compendia there is no indication that the plan's required drug(s) would likely be less 
effective and/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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta 32MG vial (J3490).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invite BRCA1, BRCA2 (breast cancer 1 and 2) panel 
(81162) provided November 17, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered genetic testing 
for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The 
Plan says the enrollee does not meet the medically necessary criteria. 
 
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. The enrollee does not have a personal history of cancer. Screening 
services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease 
predisposition are not a Medicare benefit and are not covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Invite BRCA1, BRCA2 (breast cancer 1 and 2) panel (81162) provided November 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service October 
18, 2022. 
 You asked the Plan to pay for procedure code(s) G0416. You say that this claim was coded correctly and 
should be paid. The Plan denied your request. The Plan says this code is included in the facility payment and is 
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) G0416. 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) G0416. Based on this information, 
we decided that Medicare rules for coverage of procedure code G0416 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) G0416 billed for date of service October 18, 
2022.