Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have the torus removal surgery 
approved to be able to get dentures. You say you can't eat without these dentures. The Plan denied your 
request. The Plan says the services requested are not covered under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of torus mandibularis (D7473 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) 
rendered on January 3, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says documentation regarding the enrollee's history, current symptoms, ailments, and/or 
diagnosis is needed to determine the medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the LCD requires medical notes that includes a history, physical examination, and concordant 
radiological image-based diagnostic testing that supports the diagnosis. Medical notes are also needed that 
show pain duration of at least four weeks with failure of or inability to tolerate noninvasive conservative 
care. This lack of documentation precludes meeting the LCD criteria and therefore the injections were not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection(s), of diagnostic or therapeutic substance(s) rendered on January 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic Acid or Prolia is required before alternatives can be considered. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64479). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD criteria for 
a repeat ESI is greater than 50% pain relief for 3 months. That time period has not passed yet. Therefore, the 
request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (64479).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services rendered from November 
10, 2022, to November 18, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim were supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A40.8 and DRG 854. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that although cellulitis and osteomyelitis were supported in the documentation, sepsis 
was not as the Sepsis 3 criteria were not sufficiently met. There was no indication the patient was experiencing 
a dysregulated response to infection causing life-threatening organ failure. Therefore, the documentation does 
not support a diagnosis of A40.8 (other streptococcal sepsis) and DRG 617 would be more appropriate 
according to the provided records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for acute inpatient hospital services rendered from November 10, 2022, to November 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan and 
computed tomography (CT) scan of the skull base to mid-thigh (78815).  
 
You asked the Plan to pre-approve the services. You say that  you need to know more about the unknown mass.  
The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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 services. Our physician reviewer 
found based on the medical records provided there is no documentation that you have an indication for which a 
PET/CT scan can be covered at this time as detailed in the National Coverage Determinations Manual, Section 
220.6.17(A)(2) or in the Fleischner Society guidelines for management of lung nodules. A PET/CT scan does 
not meet Medicare criteria for medically necessary and reasonable for the enrollee at this time based on the 
National Coverage Determinations Manual, Section. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan and computed tomography (CT) scan of the 
skull base to mid-thigh (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for peripheral nerve blocks rendered on January 26, 2023. 
 
You asked the Plan to pay for the blocks. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the ICD-10 codes submitted with the claim were M19.012 (primary osteoarthritis, left 
shoulder) and M75.42 (impingement syndrome of left shoulder) are not appropriate diagnosis codes for these 
peripheral nerve blocks. The review has determined that the enrollee does not have a covered indication for 
these blocks. 
 
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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pay for peripheral nerve blocks rendered on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81306, 81328, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that these lab services were medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. The Plan also says that you billed the wrong POS code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The rules also 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. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. In addition, 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 
the genetic testing provided on December 13, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 
81240, 81241, 81306, 81328, and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you were not given the correct diagnosis on 
time. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until February 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 1, 2023. 
 
You asked the Plan to pay for the medical services. You say that there are no additional claims on this date of 
service that could have caused this denial. The Plan denied your request. The Plan says you billed this claim 
with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you need the sensors so 
you can test your blood. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the supply allowance for the CGM. Our 
reviewer says that the supply allowance for a CGM coverage criteria was not met. Our physician reviewer 
found that the provided criteria indicate that a CGM will be covered if the enrollee uses insulin or has low 
blood sugars.  Although the CGM is prescribed and would likely help this enrollee, the coverage criteria are not 
met since the enrollee is not using insulin and is not having low blood sugars nor is the enrollee on medications 
that cause low blood sugars. It is also not clearly stated why the enrollee could not have their blood glucose 
monitoring needs met by a fingerstick glucometer. 
 
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 supply allowance for the CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2.  
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on May 28, 2022. 
 
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says the primary 
payer will need to review the services for payment consideration before this Plan can consider the claim for 
payment as the 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 contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for the vision services until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for vision services provided on May 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Level IV Surgical pathology services (88305) provided 
on January 26, 2023. 
 
You asked the Plan to pay for procedure code 88305. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. We find that procedure code 88305 is not supported in the 
documentation provided. Specifically, the file shows that a prostate needle biopsy specimen was collected. 
Medicare requires that surgical pathology, including gross and microscopic examination, of all submitted 
prostate needle biopsy specimens be reported with one unit of service of procedure code G0416 rather than 
procedure code 88305. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88305 have not been met. Therefore, we decided that the Plan does not have to pay for the Level IV 
Surgical pathology services (88305) provided on January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing (S9123 x1080 hours/units, S9124 
x1080 hours/units). 
 
You asked the Plan to pre-approve private duty nursing. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of private duty nursing have not been met. Therefore, we decided that the Plan does not have to pre-
approve private duty nursing (S9123 x1080 hours/units, S9124 x1080 hours/units).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 8, 2023, to 
March 24, 2023. 
 You asked the Plan to pay for the home health services. You say that you are a Medicare-certified provider and 
prior authorization is not required. The Plan denied your request. The Plan says the NOA was not received. 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 8, 2023. The NOA was not received by the Plan. As a result, 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 8, 2023, to March 24, 2023.