Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a regimen of mvasi (Q5107), dexamethasone sodium 
phosphate (J1100), thiamine HCl (J3411), vitamin B12 cyanocobalamin (J3420), magnesium sulfate (J3475), 
potassium chloride (J3480), altaplase (J2997), and pemetrexed (J9305). 
 
You asked the Plan to pre-approve the drug regimen. You say that the enrollee cannot receive any regimen with 
cisplatin due to their medical condition. The Plan denied your request. The Plan says the requested regimen is 
not approved by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 drug regimen. Our reviewer says that the requested drug regimen is not medically necessary. Our physician reviewer found the requested use of 
this drug regimen is not FDA-approved for the enrollees diagnosis. The reviewer also found that the requested 
use of this drug regimen is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested drug regimen 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 the drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a regimen of mvasi (Q5107), dexamethasone sodium phosphate (J1100), thiamine HCl 
(J3411), vitamin B12 cyanocobalamin (J3420), magnesium sulfate (J3475), potassium chloride (J3480), 
altaplase (J2997), and pemetrexed (J9305).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve D7321. We decided that the Plan does not have to pre-approve 
D7922.  
 
You asked the Plan to pre-approve an alveoloplasty (D7321), and placement of intra-socket biological dressing 
(D7922). You say that you need this dental work. The Plan says that these services have been correctly denied. 
 
 We decided that the Plan has to pre-approve D7321.  
 
Our doctor found that the medical criteria for D7321 have been met. Therefore, we decided that the Plan has to 
pre-approve D7321.  
 
We also decided that the Plan does not have to pre-approve D7922. 
 
D7922 is not a covered dental benefit. Therefore, we decided that the Plan does not have to pre-approve 
D7922. 
 
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 Guardant Reveal (81479) provided on September 25, 2022. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was medically necessary. 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 Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal (81479) provided on September 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of an oral and injectable preferred medicine (alendronate, ibandronate, pamidronate, or risedronate), and 
zoledronic acid before they will approve Prolia. The records document that the enrollee has gastrointestinal 
intolerance with bisphosphonates. She was prescribed risedronate in 2022 for about 1 month, but this was 
discontinued due to stomach upset.  The documentation does not support that alendronate, ibandronate, 
pamidronate, risedronate, and zoledronic acid would likely be less effective or have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and lab services (codes 80305 and 99214) 
billed for date of service August 19, 2022. 
 
You asked the Plan to pay for the office visit and lab services. You say that you believe that referrals were 
suspended at the time of these services due to COVID-19. The Plan denied your request. The Plan says 
insufficient information was provided to support payment of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit and lab services have 
been met. In this case, you have provided no medical records to support the services being billed.  Without 
these records, we cannot determine if the services were billed correctly or if they were medically necessary.  
The Plan has requested these records from you and none have been provided. Therefore, we decided that the 
Plan does not have to pay for the office visit and lab services (codes 80305 and 99214) billed for date of service 
August 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 17, 2022, to 
September 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 was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the billed G and Q codes do not match the billed 
dates of service. 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 August 17, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided March 
20, 2022, to April 19, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided March 20, 2022, to April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face servicey. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with an inpatient hospital POS 
code. The records do not support that the services were provided in an inpatient hospital setting. Therefore, we 
decided that the Plan does not have to pay for the services provided on November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for discharge to the next level of 
care. The Plan denied your request. The Plan says the criteria for admission to the IRF was not met and the 
enrollees needs can be provided at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgery for mandibular cancer. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not realize that you would not be covered by insurance. You also say that you are asking the Plan to reconsider 
payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SpectraCell Micronutrient testing provided on  
November 17, 2022. 
 
You asked the Plan to pay for SpectraCell Micronutrient testing. You say that the SpectraCell Micronutrient 
testing is medically necessary. The Plan denied your request. The Plan says the requested SpectraCell 
Micronutrient testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SpectraCell Micronutrient testing. Our 
reviewer says that the requested SpectraCell Micronutrient testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you were diagnosed with sinusitis, allergies, 
dermatitis, generalized anxiety disorder, insomnia, arthritis, and toxic effect of metal. SpectraCell Micronutrient testing was performed and is being requested. However, current literature does not sufficiently 
support the use of this specific nutrient panel for the listed conditions in terms of overall improved outcomes. 
Therefore, without sufficient support made, this request for SpectraCell Micronutrient testing panel will be 
considered not medically necessary at this time for this patient.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SpectraCell Micronutrient testing have not been met. Therefore, we decided that 
the Plan does not have to pay for SpectraCell Micronutrient testing provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have for reimbursement for a continuous positive airway pressure (CPAP) 
device purchased October 27, 2022. 
 
You asked the Plan for reimbursement a CPAP device. You say that your prior machine broke, and you had to 
purchase one from this supplier. You received it within a week and the in-network supplier could not tell you 
when you would be getting one from them. The Plan denied your request. The Plan says the device was 
purchased from a supplier that does not participate with Medicare. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have for reimbursement for a continuous positive airway 
pressure (CPAP) device purchased October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service January 11, 
2023. 
 You asked the Plan to pay for procedure code 86077. You say that the medical records support the services 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service January 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 2, 2022, to 
March 3, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's 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 3, 2022. The NOA was not received by the Plan until April 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided February 2, 2022, to March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that you cannot afford Part D coverage. You also 
say that you need this medication. The Plan denied your request. The Plan says the medication is not covered as 
a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 16, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were charged a copayment of $35. You say that 
you are being billed another $216. You also say that you do not understand why a copayment was collected if 
you were going to have to pay for it in full. The Plan denied your request. The Plan says the provider in this 
case does not participate with Medicare. The Plan also says that payment cannot be made for services 
performed by a provider that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 16, 
2023.