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

 
We decided that the Plan does not have to pre-approve Visco-3. 
 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 not tried and failed the 
Plan's required drugs, Orthovisc or Supartz FX. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Visco-3 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 Visco-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (Shingles) vaccine (90736) provided on May 16, 
2023. 
 
You asked the Plan to pay for the immunization service. You say that the Medicare handbook says all vaccines 
are covered. The Plan denied your request. The Plan says this is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
service. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
service. Therefore, we decided that the Plan does not have to pay for the Zoster (Shingles) vaccine (90736) 
provided on May 16, 2023.  
 
Benefits for the immunization service may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had clinical status change; thus, would be expected to require 
assessment by skilled nursing, refusing skilled therapy; thus, not appropriate for skilled therapy. The clinical 
documentation does not specify any skilled therapy needs or daily skilled nursing needs; therefore, daily skilled 
services are not supported. From a practical standpoint, clinical documentation does not support the medical 
necessity of daily skilled services on an inpatient basis in a skilled nursing facility. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical or vaginal cancer screening; pelvic and clinical 
breast examination provided on May 15, 2023. 
 
You asked the Plan to pay for cervical or vaginal cancer screening; pelvic and clinical breast examination. You 
say that you are at high risk and these services have always been paid. The Plan denied your request. The Plan 
says claim was billed as an OB/GYN exam and not high risk. Also, there was a previous claim, claim number 
820221300694880 for date of service May 9, 2022, which was also billed as an OB/GYN exam for procedure 
code G0101 that was processed and paid previously.  
 
The Plan contract covers cervical and vaginal cancer screening. For all women: Pap tests and pelvic exams are 
covered once every 24 months. If you are at high risk of cervical or vaginal cancer or you are of childbearing 
age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months. 
 
We looked at the file and the Plans rules. The file shows that you had a cervical or vaginal cancer screening; 
pelvic and clinical breast examination on May 9, 2022. Therefore, we decided that the Plan does not have to 
pay for cervical or vaginal cancer screening; pelvic and clinical breast examination provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test (0114U) provided on 
May 8, 2023. 
 
You asked the Plan to pay for the EsoGuard Esophageal DNA test (0114U). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the EsoGuard 
Esophageal DNA test (0114U) is not covered by Medicare or the Plan. 
 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. This test is currently listed as not covered by Medicare in the DEX 
Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the EsoGuard 
Esophageal DNA test (0114U) have not been met. Therefore, we decided that the Plan does not have to pay for 
the EsoGuard Esophageal DNA test (0114U) provided on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics, lift, elevation, heel and sole is medically necessary. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 16, 2023, to June 6, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that your mental health provider had to take an 
emergency medical leave and you are looking for new providers but they are either full or not accepting new 
patients. The Plan denied your request. The Plan says this provider type is on the list of individuals who are not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
May 16, 2023, to June 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99212 provided on November 30, 2022. 
 
You asked the Plan to pay for procedure code 99212. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99212 is Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and straightforward medical decision 
making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99212 is supported in the medical record. Specifically, procedure code 99212 can be 
billed in an office or other outpatient setting. The file shows the enrollee was admitted to an outpatient hospital 
facility from November 29, 2022, to December 1, 2022. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99212 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99212 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 lab services (80048, 85025) provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80048, & 85025 are not supported in the medical record. Specifically, the records do 
not include a lab order for the billed tests. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (80048, 85025) provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed with procedure codes 87500, 87641, 
87798, 87496, 87529, 87532, 87481, 87651, and 87653 provided on May 11, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed with procedure codes 87500, 87641, 87798, 87496, 87529, 87532, 87481, 87651, and 
87653 provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A vaccine (90632), Hepatitis B vaccine 
(90746), and tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715), and administrations 
(90471, 90472, G0010) provided on May 31, 2023. 
 
You asked the Plan to pay for the immunization services. You say that your doctor advised you were due for 
these vaccines. You say that you did not know that you needed to have these done at a pharmacy. You say that 
you were not aware they were not covered until you received a bill. You also say that you should be reimbursed 
for these. The Plan denied your request. The Plan says these services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccine (90632), 
Hepatitis B vaccine (90746), and tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715), 
and administrations (90471, 90472, G0010) provided on May 31, 2023.   
Benefits for the immunization services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 14, 
2022, through February 15, 2022. 
 
 
  
 
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee with a history of cardiac artery disease (CAD) and five stents presented to the 
emergency department (ED) for chest pain. The electrocardiogram (EKG) and troponin tests were negative.  
The enrollee was admitted for chest pain and to rule out acute coronary syndrome (ACS) and was placed under 
an inpatient level of care. The records do not show that at the time of the inpatient admission it was reasonable 
for the admitting physician to expect that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. Although the enrollee has a history of CAD she had an 
unremarkable EKG and two negative troponin tests. The enrollee was hemodynamically stable and was not on 
a heparin drip. 
  
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 pay for the acute inpatient hospital care provided from February 14, 2022, through February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service April 25, 
2023. 
 You asked the Plan to pay for procedure code 76380. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76380 is bundled into payment for code 
78803. 
 
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 76380 
is a column II code to column I code 78803. 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 76380 billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a noninvasive ventilator (E0466). 
 
You asked the Plan to pre-approve a noninvasive ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested Trilogy ventilator is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a noninvasive ventilator. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of a 
neuromuscular disease (myasthenia gravis) and obstructive sleep apnea. Provided records document that the 
home ventilator is being requested for use in an average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. Provided records in this case do not provide adequate detailed information to meet Medicare 
criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a noninvasive ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a noninvasive ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. 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 a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for Q0092. We decided that the Plan does not have to pay for R0070.  
 
You asked the Plan to pay for code R0070, defined as the transportation of portable x-ray equipment and 
personnel to a home or nursing home, per trip to facility or location, one patient seen, and code Q0092, defined 
as set up of portable x-ray equipment, billed on December 9, 2022. You say that R0070 and Q0092 should be 
paid as billed because they were billed by a mobile radiology provider. The Plan says that R0070 and Q0092 
are denied because they are not supported in the documentation. 
 
We decided that the Plan has to pay for Q0092.  
 
The Plan follows Medicare rules. Medicare rules say that for portable x-ray services, carriers must pay a set-up 
component for each radiologic procedure (other than retakes of the same procedure) during both single patient 
and multiple patient trips under Level II HCPCS code Q0092. 
 
Records support that a portable x-ray service was done. Therefore, we decided that the Plan has to pay for 
Q0092.  
 
We also decided that the Plan does not have to pay for R0070. 
 
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for 
any item or service, the information submitted by the supplier or provider must corroborate the documentation 
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. No 
transportation charge is payable unless the portable x-ray equipment used was actually transported to the 
location where the x-ray was taken. 
 
Records do not contain any documentation of the transportation of portable x-ray equipment and personnel to 
the location where the x-ray services were provided. Therefore, we decided that the Plan does not have to pay 
for R0070. 
 
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 lab services provided on June 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 15, 2023.