Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for procedure code 96040. You say that there is no other service on this date. The 
Plan denied your request. The Plan says procedure code 96040 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
96040 billed for date of service April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on April 10, 2023, for 
knee and hip pain.  
 
You asked the Plan to pay for the acupuncture services. You say that you were told this was covered, and the 
provider billed a different diagnosis without your consent. The Plan denied your request. The Plan says this 
service was provided for knee and hip pain, which is not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were provided for knee/hip pain. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on April 10, 
2023, for knee and hip pain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Myeloid Molecular Profile genetic testing (81455) 
provided on July 22, 2022. 
 
You asked the Plan to pay for the Myeloid Molecular Profile genetic testing (81455). You say that the Myeloid 
Molecular Profile genetic testing provided was medically necessary.  The Plan denied your request. The Plan 
says the Myeloid Molecular Profile genetic testing provided was 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 the Myeloid Molecular Profile genetic 
testing (81455). Our reviewer says that the Myeloid Molecular Profile genetic testing provided was not 
medically necessary.  Our physician reviewer found there are no indications of a myeloproliferative disorder. 
Molecular testing for a myeloproliferative disorder is not reasonable and necessary. The enrollee needs marrow 
for anemia diagnosis. 
 
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 Myeloid Molecular Profile genetic testing (81455) have not been met. 
Therefore, we decided that the Plan does not have to pay for the Myeloid Molecular Profile genetic testing 
(81455) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need more rides because you go 
to dialysis three times per week, and have no other method of transportation. The Plan denied your request. The 
Plan says you have used fifty-three (53) of the allowed sixty (60) trips for routine transportation, you have 
seven (7) remaining and will have exceeded your benefit limit. The Plan also says this request is not covered by 
your health plan.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that as of August 31, 
2023, you had used 53 of the allowed 60 trips for routine transportation, and you have 7 trips remaining. Based 
on this information, we decided that after the 7 trips remaining, this request exhausts the Plan maximum benefit 
for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 20, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 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 billed services was not filed until March 15, 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 lab testing billed for date of service April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing billed for date of service 
February 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test analyzes variations that may affect the 
response to medications. The Plan denied your request. The Plan says this testing is not the standard of care. 
 
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. The provided pharmacogenetic testing was reportedly ordered to 
make decisions about the patient's medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on a response to the medication. It is not necessary to do genetic testing 
to provide or adjust medications. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing 
billed for date of service February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 11, 2021. 
 
You asked the Plan to pay for the billed services. You say that the documentation shows the claim was filed. 
The Plan denied your request. The Plan says the 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 billed services was not filed until March 31, 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 lab testing billed for date of service August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ILR is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has no history of atrial 
fibrillation and no significant cardiac arrhythmias were noted on electrocardiogram (ECG) monitoring. A 
recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed 
by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history 
of atrial fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and 
necessary in the enrollee's clinical management. 
 
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 an implantable loop recorder (ILR).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
15, 2022, to December 22, 2022. 
 You asked the Plan to pay for SNF care. You say that these services were medically necessary. The Plan denied 
your request. The Plan says the requested service was not medically necessary because the enrollee did not 
have daily skilled therapy or nursing needs. 
 
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 pay for 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 did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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 pay for skilled nursing facility (SNF) care provided from December 15, 2022, to December 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has experienced intolerable side 
effects with anticholinergics. 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 Myrbetriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with single 
power option (K0856). 
 
You asked the Plan to pre-approve the K0856 power wheelchair. You say that it is felt that this PWC should be 
covered. The Plan denied your request. The Plan says the requested PWC base does not meet criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with a single power option may only 
be covered when the enrollee meets criteria for a power tilt or power recline seating system. 
 
 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 K0856 power wheelchair. Our 
reviewer says that the K0856 power wheelchair does not meet coverage criteria. Our physician reviewer found 
the enrollee has a neurologic disorder with functional deficits.  The documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder or have spasticity that 
would necessitate power tilt or recline. Although the members condition may meet criteria for a PWC, the 
criteria for this specifically requested PWC with multiple power options including power tilt are not met.  
 
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 K0856 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with single power option (K0856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit on March 9, 2023. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you have never had any issues with this 
before and want it covered. The Plan denied your request. The Plan says that the original decision to deny 
coverage was correct. 
 
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 the office visit on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may offer a Point of Service (POS) option 
and may either require or waive prior authorization rules for obtaining POS services. The Plan contract states 
that prior authorization is required for out-of-network (OON) physician/practitioner services and skilled 
nursing facility care.  
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of OON nursing facility care have not been met. Therefore, we 
decided that the Plan does not have to pay for nursing facility care provided on October 27, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services occurred during the pandemic, so 
this claim should be reconsidered. The Plan denied your request. The Plan says you did not timely file your 
claim. 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 lab services was not filed until April 26, 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 lab 
services provided on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of bilevel positive airway pressure 
(BiPAP) (E0471). 
 
You asked the Plan to pre-approve continuation of BiPAP. 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 the term PAP (positive airway pressure) device will 
refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist 
device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea. 
 
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 continuation of BiPAP. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has obstructive sleep apnea and is being treated with the requested device. The record provided does 
not indicate compliance with use of the device greater than four hours per night on 70% of nights during a 
consecutive thirty (30) day period. The elements of the coverage criteria to continue therapy are not satisfied. 
The requested service is not 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 continuation of BiPAP have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continuation of bilevel positive airway pressure (BiPAP) (E0471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 rendered on December 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation do not support the procedures 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 11042 is "Debridement, subcutaneous tissue (includes 
epidermis and dermis, if performed); first 20 sq cm or less." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedural portion of the 
medical records provided does not include sufficient documentation the validate that CPT 11042 was performed in this case. This procedure cannot be verified. 
 
We looked at this coder'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 procedure code 11042 rendered on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services occurred during the pandemic, so 
this claim should be reconsidered. The Plan denied your request. The Plan says you did not timely file your 
claim. 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 lab services was not filed until April 21, 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 lab 
services provided on November 27, 2021.
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 the enrollee has tried alendronate but reported an upset 
stomach. You say that Prolia is the next step in therapy for osteoporosis and the denial should be reconsidered. 
The Plan denied your request. The Plan says the enrollee must first try or be unable to use the Plans preferred 
medications. 
 
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 
enrollee has not tried and failed the required drug. Our physician reviewer found there is no documentation 
provided indicating that the Plan's required drug would likely be less effective or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 17, 2023, 
through April 19, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the stay is 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of admission, the enrollee was determined to no longer need bilevel 
positive airway pressure (BiPAP) and was tolerating low dose oxygen and was awake and alert with stable 
vitals. It was not expected that the enrollee would have required hospital services that would have likely 
crossed 2 midnights due to this clinical response and stability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided April 17, 2023, through April 19, 2023.