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

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires ongoing daily physical and 
occupational therapy to make a full recovery. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have documented skilled therapy needs. The enrollee is 
functioning below her baseline. A trial of skilled therapy is reasonable to see if time, pain control and an out-
of-hospital environment allows her to achieve her prior level of function. Daily skilled services are required to 
establish a maintenance program or to prevent deterioration of the enrollees 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service February 8, 
2023. 
 
You asked the Plan to pay for procedure code 11720. You say that the physician provided medically necessary 
services that meet the professionally recognized standards of healthcare, and the claim should be processed for 
payment. The Plan denied your request. The Plan says payment for code 11720 is bundled into payment for 
code 11719. 
 
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, we have confirmed that code 11720 
is a column II code to column I code 11719. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11720 billed for date of service February 8, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204, 74230, 74240, 72040, 70100, and 
70310 for date of service January 25, 2023. 
 
You asked the Plan to pay for procedure codes 99204, 74230, 74240, 72040, 70100, and 70310 . 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 providers must report services correctly.  
 
We find that CPT codes 99204, 74230, 74240, 72040, 70100, and 70310 are not payable as billed. Specifically, 
these codes were billed with place of service 11 (office). However, the documentation shows that the services 
were provided in a mobile setting at a skilled nursing facility (SNF). This means the place of service billed is 
not supported. The documentation shows that the services were performed at a nursing home (via mobile 
van/portable x-ray) which are denied as an excluded place of service. This means codes 74230 and 74240 are 
not covered. Based on this information, we decided that Medicare rules for coverage of procedure codes 99204, 
74230, 74240, 72040, 70100, and 70310 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99204, 74230, 74240, 72040, 70100, and 70310 for date of service January 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for procedure code 97014. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 97014 billed for date of service March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the submitted medical records support 
the need for LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, 
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 the enrollee appears to be somewhat unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable for transfer. The enrollee does not 
require services at the LTACH that are not already available at the current facility.  Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and it would not 
be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 31, 2022, to 
September 29, 2022. 
 You asked the Plan to pay for the home health services. You say that it was not clear that the Plan was going to 
require NOAs.  Once you discovered that the Plan required them, you submitted the NOA. 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 August 31, 2022. The NOA was not received by the Plan until November 3, 
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 August 31, 2022, to September 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled home physical therapy (PT) (G0151x20), skilled 
home occupational therapy (G0152x20) and skilled home nursing services (G0299x20) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve home health services. You say that you disagree with the denial and request 
reconsideration.  The Plan denied your request. The Plan says there is an in-network home health agency that 
can provide the care and services the enrollee needs. 
 
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 
skilled home physical therapy (PT) (G0151x20), skilled home occupational therapy (G0152x20) and skilled 
home nursing services (G0299x20) 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 the laboratory services rendered on February 17, 2023. 
 
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 
February 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 25, 2022, to 
April 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you did not know that the Plan was going 
to require NOAs. Once you confirmed that the Plan did require it, the NOA was submitted. 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 March 25, 2022. The NOA was not received by the Plan until June 15, 
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 March 25, 2022, to April 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on December 16, 
2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 06, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary. 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 Feraheme. Our reviewer says that the 
step therapy requirements have not been met. Our physician reviewer found that the record indicates that the 
enrollee has iron deficiency anemia. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you received a verbal approval to see this out-
of-network provider. The Plan denied your request. The Plan says you must receive your care from a 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit 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 Injectafer. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drug, Venofer. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Injectafer is 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 Injectafer.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has 
not tried and failed the Plan's required drugs, Fosamax, Fosamax Plus D, Actonel, Atelvia, or Boniva. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Reclast is 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 Reclast.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa, once weekly for three weeks. 
 
You asked the Plan to pre-approve Euflexxa. You say that this should be approved. The Plan denied your 
request. The Plan says the enrollee did not have significant pain relief from the last injection. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat series of injections may be allowed 
when the indications continue to be met, significant improvement in pain and functional capacity from the prior 
series of injections is documented in the medical record, and the last injection was given at least six months 
ago.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Euflexxa, once weekly for three weeks.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Euflexxa 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 Euflexxa. Our reviewer says that 
treatment with Euflexxa Our physician reviewer found that the Plan requires a trial of drugs Monovisc, 
Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. The enrollee in this case has 
not tried and failed the required drugs. There is no documentation provided indicating that the Plans required 
drugs 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on February 03, 2023. 
 
You asked the Plan to pay for injections. You say that prior authorization is not needed for this service. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
February 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG testing provided on January 17, 2023. 
 
You asked the Plan to pay for the Tempus xG testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xG test is not FDA approved nor 
does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare 
rules for coverage of the Tempus xG testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xG testing provided on January 17, 2023.