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

 
We decided that the Plan does not have to pay for lab services (81295, 81298) provided on April 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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, we have confirmed that codes 
81295 and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81295, 81298) provided on April 8, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (A4595) provided on May 
14, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment (A4595) provided on May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder test (0013M) provided on April 22, 2022. 
 
You asked the Plan to pay for the CX Bladder test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CX Bladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the CX Bladder test (0013M) provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on January 1, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you submitted your request for 
reimbursement untimely; therefore, the health club membership is not payable.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because your request for reimbursement of  
the health club membership purchased was submitted untimely. The Plan contract states that your request must 
be received no later than March 31
st
 of the following year.  The Plan received your request for reimbursement on May 5, 2022, which was untimely. Therefore, we decided 
that the Plan does not have to issue reimbursement for the health club membership (S9970) purchased on 
January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for ambulance services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana. 
 
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 unspecified chronic 
obstructive pulmonary disease (COPD). He has not tried and failed the Plan's required drug, Perforomist. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Brovana 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 Brovana.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says as member of our plan, the enrollee can choose to receive care from out-of-
network providers. However, please note providers that do not contract with us are under no obligation to treat 
the enrollee, except in emergency situations. Our plan follows National and/or Local Coverage Determinations 
(NCD/LCD) and other CMS regulatory guidelines and will cover services from either network or out-of-
network providers as long as the services are covered benefits and are medically necessary. However, if the 
enrollee uses an out-of-network provider, their share of the costs for the covered services may be higher.  
 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional rides to 
your medical appointments. The Plan denied your request. The Plan says to date, you have used 100 of the 100 
allotted trips under the 2022 benefit for transportation, and have 0 trips remaining for the 2022 calendar year. 
 
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 100 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genomic Testing Cooperative (GTC) Hematology Next 
Generation Sequencing (NGS) Profile provided on February 3, 2022. 
 
You asked the Plan to pay for the GTC-Hematology NGS Profile. You say that the GTC-Hematology NGS 
Profile provided on February 3, 2022, was medically necessary. The Plan denied your request. The Plan says 
the GTC-Hematology NGS Profile provided on February 3, 2022, 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 GTC-Hematology NGS Profile. Our 
reviewer says that the GTC-Hematology NGS Profile provided on February 3, 2022, was not medically 
necessary. Our physician reviewer found the enrollee underwent a bone marrow biopsy which was sent for next 
generation sequencing. Rationale for the bone marrow biopsy is not provided. Therefore, it cannot be 
determined if the test was 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 the GTC-Hematology NGS Profile have not been met. Therefore, we decided 
that the Plan does not have to pay for the Genomic Testing Cooperative (GTC) Hematology Next Generation 
Sequencing (NGS) Profile provided on February 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (ultrasound) of lower 
extremity arteries provided on June 08, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan (ultrasound) of lower extremity arteries. You 
say that the services were a result of a flawed surgery, and you should not be charged. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $40 copayment for the duplex scan (ultrasound) of lower extremity arteries. This 
item/service falls within the radiological diagnostic services, not including x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan 
does not have to waive the copayment for the duplex scan (ultrasound) of lower extremity arteries provided on 
June 08, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto (lutetium Lu-177 vipivotide tetraxetan). 
 
You asked the Plan to pre-approve Pluvicto (lutetium Lu-177 vipivotide tetraxetan). You say that the requested 
Pluvicto (lutetium Lu-177 vipivotide tetraxetan) is medically necessary. The Plan denied your request. The 
Plan says the requested Pluvicto (lutetium Lu-177 vipivotide tetraxetan) is not medically necessary. 
 
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 Pluvicto (lutetium Lu-177 vipivotide 
tetraxetan). Our reviewer says that the requested Pluvicto (lutetium Lu-177 vipivotide tetraxetan) is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of 
metastatic prostate cancer. The record does not indicate that the enrollee has received previous chemotherapy. 
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 Pluvicto (lutetium Lu-177 vipivotide tetraxetan) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Pluvicto (lutetium Lu-177 vipivotide tetraxetan).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the humidifier, heated, used with positive 
airway pressure device (E0562) provided April 25, 2022 
 
You asked the Plan to waive the coinsurance for the humidifier. You say that you were informed that the 
humidifier chamber is charged separately as an individual item. The CPAP will not function without its 
humidifier chamber. You request for the Plan to instruct the supplier to refund or credit $32.45 to your account. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of 
the total cost for each Medicare covered item for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $37.88. ($189.40 allowed amount x 20%) 20% the humidifier. This item/service 
falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the humidifier, heated, used with positive airway pressure device 
(E0562) provided April 25, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) provided 
on November 19, 2021. 
 
You asked the Plan to pay for the therapeutic CGM. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment cannot be made for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapeutic continuous glucose monitor (CGM) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the office visit. The Plan denied your request. The Plan says the medical 
care you require can be provided by a network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand finger orthoses (HFO), without joints (L3924, 
RT/LT) provided May 11, 2022. 
 
You asked the Plan to pay for the orthoses. You say that your previous supports had a metal support pieces in 
them which began to cause issues with your arthritis. Your provider explained that these new supports would 
be more medically sufficient for your needs. The Plan denied your request. The Plan says the reasonable useful 
lifetime requirement has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you had L3924-RT and L3927-LT at the time the orthoses were received. The records show 
that these were received May 11, 2021, and payment was approved by the Plan. L3924-RT and L3927 serves the same purpose as the orthoses. Therefore, we decided that the Plan does not have to pay for the hand finger 
orthoses (HFO), without joints (L3924, RT/LT) provided May 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the routine venipuncture (36415) provided on February 15, 2022. 
 
You asked the Plan to pay for the routine venipuncture. You say that this service was approved the last time it 
was done. The Plan denied your request. The Plan says that this service is non-covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case it does not appear that routine venipuncture is not covered by 
Medicare. The Plan has not provided any support for their claim that the requested service is a non-covered 
service. Therefore, we decided that the Plan has to pay for the routine venipuncture (36415) provided on 
February 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transfer bench, Hospital bed, over-bed table, and misc 
DME (E0265, E1399, E0274, E0248) provided on January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they were non-emergent and 
prior authorization was not obtained. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a transfer bench, Hospital bed, over-bed table, and 
misc DME (E0265, E1399, E0274, E0248) provided on January 12, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate 4Kscore test algorithm (81539) provided April 
21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provider ordered the 4Kscore test as a 
safe and effective method to aid in evaluating the need for a prostate biopsy for the enrollee. The Plan denied 
your request. The Plan says the records do not support that the Medicare criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The medical necessity criteria for this testing requires a Prostate-
Specific Antigen (PSA) above three and less than 10 in a man of this members age. Since the enrollees PSA 
is greater than 10, this testing does not meet medical necessity requirements. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the prostate 4Kscore test algorithm (81539) provided April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit. 
 
You asked the Plan to pre-approve an office visit. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received 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 office visit.