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 provided from May 4, 2022, to June 
2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 4, 2022, to June 2, 
2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from October 12, 2022, 
to January 1, 2023. 
 
You asked the Plan to pay for the SNF services. You say that you have gathered the requested revenue codes 
and bills and have sent them to the Plan. The Plan denied your request. The Plan says that payment is not 
allowed because it was billed without a revenue code or description of the service. 
 
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 Plan's sole reason for denial is that this service was billed 
without a revenue code or a description of the service.  However, you have provided proof that you sent 
revenue codes and a description of the services via fax to the Plan on July 26, 2023.  There is no evidence that 
the Plan has reviewed or responded to this additional information.  There is no evidence that the Plan has 
determined that this information is insufficient.  The Plan has made no other argument for non-coverage.  
 
In addition, the Plan's own Evidence of Coverage states that if you are billed by a provider, you should send the 
bill to the Plan, along with documentation of any payments you have already made. (Please see page 137 of the 
2023 Evidence of Coverage).  You have done all of this.  You have provided all of the bills and proof of 
payment that is listed in this Plan contract document, in addition to the requested revenue codes.  At this time, 
the Plan has provided no argument as to what is still lacking or missing in order to pay these claims.  The 
burden is on the Plan to show why its decision to deny was correct.  By failing to address this in its case file 
submission (or via additional information submitted to us after they sent the case file to us), we find that the 
Plan has not met this burden. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) 
services provided from October 12, 2022, to January 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 13, 2023, to 
January 23, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that it is medically necessary. The Plan denied 
your request. The Plan says they cover only manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on January 13, 2023, to January 23, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound, transvaginal and ultrasound, pelvic provided on  
March 31, 2023. 
 
You asked the Plan to pay for the ultrasound, transvaginal and ultrasound, pelvic. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that these are not a Medicare benefit 
for the diagnoses listed on the claim and are done for screening purposes. 
 
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 Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for an ultrasound, transvaginal 
and ultrasound, pelvic provided on March 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee clearly meets the Food and Drug Administration (FDA) indications for use. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document the Intracept procedure is safe and effective, not 
mainly for the convenience of the patient or the physician, not experimental or investigational, is appropriate, is 
furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
patient's condition or to improve the function of a malformed body member, is furnished in a setting appropriate to the patient's medical needs and condition, is ordered and furnished by qualified personnel, is one 
that meets, but does not exceed, the patient's medical need and is at least as beneficial as an existing and 
available medically appropriate alternative as required by the Social Security Act, Section 1862 (a)1(A) and the 
42 CFR Section 411.15(k). 
 
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 Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you have had bladder issues since you 
were 14 years old. You said that you need these incontinence supplies so that you do not urinate on yourself. 
The Plan denied your request. The Plan says incontinence supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 20, 2022, to 
February 18, 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 services are not supported. 
 
The Plan must follow Medicare rules. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the submitted documentation does not support the 
billed HIPPS code. 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 home health services 
rendered from January 20, 2022, to February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac rhythm device evaluation provided on July 22, 
2022, by an OON provider.  
 You asked the Plan to pay for the device evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service is not covered when received out-of-
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract also says that out-of-network diagnostic 
procedures and tests are not covered. 
 
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 cardiac rhythm device evaluation provided on 
July 22, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve 
through the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is not 
medically necessary. The Plan says the radiologic studies show additional significant pathologies that are 
unlikely to benefit from the procedure. The Plan denied your request. The Plan says the enrollee has tried and 
failed conservative treatment without relief. 
 
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 Intracept procedure. Our reviewer 
says that the requested surgery not considered medically reasonable and necessary in this case. Our physician 
reviewer found magnetic resonance imaging (MRI) shows multiple degenerative pathologies and the cause of 
pain is not clear. In this case, there is no MRI with only modic changes. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intraosseous ablation of the basivertebral nerve through the Intracept 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 25, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 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 that you have a diagnosis of knee 
osteoarthritis. You have not tried and failed the Plan's required drugs, Orthovisc or Synvisc. The records do not 
show that the required drugs would be less effective or have negative effects; therefore, Euflexxa is not 
reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you should not be charged for these 
services. The Plan denied your request. The Plan says the primary payer will need to review the services for 
payment consideration before they can consider the claim for payment as secondary payer. 
 
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 called the 
providers billing office to advise them to bill your primary insurance. As the secondary insurer, the Plan 
cannot be held responsible for the laboratory 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 provided on 
February 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care services provided on April 12, 2023. 
 
You asked the Plan to pay for the mental health care services. You say that the services were medically 
necessary. 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 the mental health care 
services provided on April 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 You asked the Plan to pre-approve Darzalex. You say that the enrollee will be starting treatment for their 
cancer. 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 Darzalex. Our reviewer says that 
Darzalex is not medically necessary. Our physician reviewer found that the enrollee has multiple myeloma, and 
the medication is a new start. However, there is no indication that the enrollee has tried and failed the Plan's 
preferred step one alternative. Also, there is no indication that the enrollee has a contraindication to or would 
have an adverse effect from the Plan's preferred step one alternative. Therefore, the elements of coverage 
criteria are not satisfied and, the requested service cannot be 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 Darzalex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services (22830, 22852) provided on 
January 27, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that these services were necessary and should 
be paid. The Plan denied your request. The Plan says these services were billed with two modifiers which 
cannot be reported together. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that staged procedures (reported with modifier -58) do not apply to assistant at surgery claims. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of surgical assistant services have not been met. Specifically, these services were reported with both 
modifiers -58 and -AS for surgical assistant services. However, modifier -58 does not apply to surgical 
assistant services. Therefore, we decided that the Plan does not have to pay for surgical assistant services 
(22830, 22852) provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (11721, 99310) provided on February 14, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized. 
 
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 outpatient services (11721, 99310) provided on 
February 14, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
12, 2023. 
 
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. 
 
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 (81455) provided on February 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens fitting provided on March 7, 2023. You asked the Plan to pay for the contact lens fitting. The Plan denied your request. The Plan says per your 
Evidence of Coverage, the contact lenses are covered but the fitting is not. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The file shows that the Plan covers routine eyewear; however there is 
no coverage for contact lens fitting. Therefore, we decided that the Plan does not have to pay for contact lens 
fitting provided on March 7, 2023.