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

 
We decided that the Plan does not have to pay for five units of surgical pathology services (88305), four units 
of 88173, four unit of 88172, and seven unit of 88177 for pathology services provided on May 17, 2019. 
 
You asked the Plan to pay for the pathology services. You say that this was billed correctly for medically 
necessary testing. The Plan denied your request. The Plan says this was not correctly billed. Payment was made 
for one unit of 88173 and 88305 as only one unit was supported. 88172 is included in payment for 88333 for 
which a modifier must be billed for separate payment to be made. 
 
The Plan must follow Medicare rules. Medicare rules say that Column 1/Column 2 NCCI edits only allow 
payment for the Column 2 code if a clinically appropriate modifier is used. In addition, the rules say that the 
unit of service for surgical pathology is per specimen.  
 
In this case, the documentation does not support five units of 88305 as less than five specimens are recorded. 
Four units of code 88173 (Cytopathology, evaluation of fine needle aspirate) is not supported as the 
documentation does not show four fine needle aspirates. Code 88172 is a Column 2 code in relation to 88333 
and no clinically appropriate modifier was reported to allow separate payment. As such, the add-on code 88177 
cannot be paid either. Based on this information, the services as billed are not supported. Therefore, we decided 
that the Plan does not have to pay for five units of surgical pathology services (88305), four units of 88173, 
four unit of 88172, and seven unit of 88177 for pathology services provided on May 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 23, 2020 to March 3, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this service should be 
covered because you have been given different information. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment per day for days 1-5 and $0 after day 5 each time you are admitted to an inpatient 
acute care hospital.  
 
The enrollee has been asked to pay a $350 copayment per day for days 1-5 for the inpatient hospital stay. ($350 
x 5 = $1,750). The inpatient hospital stay falls within the "Inpatient hospital stay" benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided from January 23, 2020 to 
March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing services provided on February 11, 2020. 
 
You asked the Plan to pay for the nursing services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nursing services provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup.
You asked the Plan to pre-approve the core buildup. You say that due to the enrollee's health conditions, it is medically necessary to have good dentition and to receive the dental work. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 the core buildup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home oxygen (E0431). 
 
You asked the Plan to pre-approve home oxygen. You say that the oxygen is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 home oxygen. Our reviewer says that 
the oxygen equipment is not medically necessary. Our physician reviewer found arterial blood gas results have 
not been submitted for review.  As such, the documentation does not clearly denote that the enrollee meets 
coverage criteria for home oxygen use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home oxygen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home oxygen (E0431).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor.
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 item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM and supplies are covered for beneficiaries who are diabetic and insulin-treated who meet specific criteria. We looked at the file and Medicare rules. The file shows that you are not insulin-treated. 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 a Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life Alert emergency alert system. 
 
You asked the Plan to pre-approve the Life Alert emergency alert system. You say that you believe the enrollee 
needs the services. Please review the documentation and reconsider. The Plan denied your request. The Plan 
says these are emergency communications systems and do not serve a diagnostic or therapeutic purpose and is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Life Alert emergency alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is needed to ensure that the fracture heals 
properly. The Plan denied your request. The Plan says there is no non-union as demonstrated by x-rays taken 
90 days apart. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found not enough 
time has passed to establish a diagnosis of non-union. The criteria for this bone stimulator is 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone growth stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty. 
 
You asked the Plan to pre-approve blepharoplasty. You say that the requested blepharoplasty is medically 
necessary. The Plan denied your request. The Plan says the requested blepharoplasty does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve blepharoplasty. Our reviewer says that 
the requested blepharoplasty does not meet criteria. Our physician reviewer found the enrollee is with a 
diagnosis of blepharochalasis of the right upper eyelid with a request for blepharoplasty. Pictures, visual 
confrontation fields and a note from the attending physician is included to review.  
 
There is no significant difference in the visual confrontation fields between taped and untaped determinations. 
This is confirmed by the attending physician note of June 30, 2020. There is no documentation of reading or 
other functional difficulties. Therefore, the requested procedure does not satisfy the requirements outlined in 
Local Coverage Article: Blepharoplasty - Medical Policy Article (A52837) to ascertain that the requested 
procedure is for functional limitations rather than cosmetic purposes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve blepharoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement below the knee prosthesis. 
 
You asked the Plan to pre-approve the prosthesis replacement. You say that you were told by an orthopedist 
that you needed to have this prosthesis replaced. The Plan denied your request. The Plan says office notes do 
not show that replacement was recommended by the orthopedist or prosthetist. The prosthetic limb is also not 
old enough to be replaced as it is less than five years old. 
 
The Plan follows Medicare rules. Medicare rules say that replacement of a prosthesis is covered when the 
above referenced 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 the prosthesis replacement. Our 
reviewer says that the requested replacement is not shown to be reasonable and necessary. Our physician 
reviewer found There is an office visit dated 6/25/20 by the patient's physician. These notes state the patient has 
severe dystrophic ulcers of the left lower extremity stump. He was seen by orthopedic who recommended new 
inserts. Physical exam shows the patient has a well-fitting below the knee prosthesis. He can fully extend the 
knee and flex 135 degrees. There is slight diffuse tenderness around the quadriceps tendon, 2-3 inches above 
the patella. There is slight tenderness over the fibula where it appears as though there may be inadequate, cut 
off in the socket of his BKA prosthesis. Radiographs of the knee were good with normal joint spaces and the 
knee itself has normal examination. The plan was to consider physical therapy and getting his socket adjusted. 
 
The documentation does not show that the policy article criteria for replacement are met. There is no evidence 
that replacement is medically reasonable and necessary in spite of the criteria in the rules. There is no evidence 
that the replacement of a prosthesis or prosthetic components  is required because of loss or irreparable 
damage. 
 
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 prosthesis replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement below the knee prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #29. 
 
You asked the Plan to pre-approve the crown. You say that a crown is required for tooth #29. The Plan denied 
your request. The Plan says the Plan has approved the enrollee's maximum allowable 2020 benefit for crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to 2 per 1 calendar 
year. The record shows that as of June 17, 2020, the Plan has approved two crowns (D2750 x2), and the 
enrollee's crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
a crown (D2750) for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary denture (D5130) and immediate 
mandibular denture (D5140). 
 
You asked the Plan to pre-approve the immediate maxillary and mandibular dentures. You say that the enrollee 
really needs the dentures because their mouth is in really bad shape. The Plan denied your request. The Plan 
says the enrollee's dentures benefit has been exhausted. The Plan also says that only one set of dentures is 
covered per arch every 60 months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures and are limited to one per 
arch every 60 months. The record shows that the enrollee was approved for a complete maxillary denture 
(D5110) and complete mandibular denture (D5120) on July 23, 2020, and the enrollee's maxillary and 
mandibular dentures benefit has been exhausted.  
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve an immediate maxillary denture (D5130) and 
immediate mandibular denture (D5140).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve stab phlebectomy services.
You asked the Plan to pre-approve the stab phlebectomy services. You say that you are in a lot of pain and have severe cramps. You say that you have a tough time sleeping due to the pain and cramps. You say that you have a lot of itching and breakouts below the ankle of your left foot. You say that you have had the procedure done in the past on your upper left foot. You say that you have swelling on the bottom left leg where the itching and pain is severe. The Plan denied your request. The Plan says that the enrollee does not meet the medical necessity criteria for management of varicose veins.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the stab phlebectomy services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the treatment in question and coverage criteria have been met. There is satisfactory documentation of severe symptoms despite conservative efforts. The greater saphenous veins have been ablated. There is no significant reflux in the small saphenous veins or perforator veins.
The photos document massive varicosities that easily fit into the coverage size criteria. There is satisfactory documentation of adequate lower extremity arterial perfusion. The proposed plan appears to be both appropriate and 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 the stab phlebectomy services have been met. Therefore, we decided that the Plan has to pre-approve stab phlebectomy services.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 2, 2020 to 
March 3, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs could have been met at a lower 
level of care. 
 
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 the patient appeared stable and could have been managed in the observation setting. 
There was no indication that more than a two-midnight stay in the hospital was needed. 
 
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 March 2, 2020 to March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve an MRI. You say that you have moved and you would like to be able to get 
these services done locally now. The Plan denied your request. The Plan says these services can be provided in-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an MRI to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 7, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 22, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not include a valid physician order, lab requisition, or 
medical records stating exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 18, 2020. 
 
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 the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 18, 2020.