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

 
We decided that the Plan does not have to pay for the wound care services provided on August 21, 2021. 
 You asked the Plan to pay for the services provided. You say that the codes were appropriately identified as 
separate services. The Plan denied your request. The Plan says an appropriate modifier was not 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 code 12002 is a column II code to column I code 29130. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the wound care 
services provided on August 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says outpatient self-
administered medications are not covered by this 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 Prednisone.  
 
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the eye exam (92014) provided on 
December 8, 2021, by an out-of-network provider. 
 
You asked the Plan to waive the coinsurance for the eye exam. You say that you believed this provider was in-
network, and you found this provider through the Plan's website. The Plan denied your request. The Plan says 
this claim was processed correctly, and your cost-share was assessed in accordance with your contract. 
 
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 50% 
coinsurance for Medicare-covered vision services received out-of-network.  
 You have been asked to pay 50% coinsurance for the eye exam which was performed by an out-of-network 
specialist. The record shows that the initial amount billed for this service was $110, and the Plans allowed 
amount (discounted rate) is $75. You are responsible for 50% coinsurance on the Plans allowed amount for 
out-of-network vision services. Please note that in this case, this is less than the $50 copayment for in-network 
services. In addition, the attached screen included with your appeal shows select network in the top right 
corner, which indicates that you did not provide your specific plan information to get accurate network results 
when you performed this search. 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 eye exam (92014) 
provided on December 8, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat colonoscopy (45378). 
 
You asked the Plan to pre-approve a repeat colonoscopy. The Plan denied your request. The Plan says 
surveillance colonoscopy can be repeated every 24 months in high-risk individuals. The Plan also says that it 
has only been 15 months since the enrollee's last colonoscopy. 
 
The Plan follows Medicare rules. Medicare rules say that screening colonoscopies may be paid when 
performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at 
high risk for developing colorectal cancer. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a repeat colonoscopy. Our reviewer 
says that a repeat colonoscopy is not medically reasonable or necessary at this time. Our physician reviewer 
found the guidelines support high risk individuals, such as this enrollee, be surveyed via colonoscopy every 24 
months, so this request for repeat colonoscopy is premature and will be considered not medically necessary or 
appropriate at this time, as the last colonoscopy was only 15 months prior to this request. Our reviewer also 
found that a request may be considered after 24 months have passed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat colonoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat colonoscopy (45378).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on December 9, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the injection services provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX Melanoma testing provided on November 
22, 2021. 
 
You asked the Plan to pay for the DecisionDx Melanoma testing. You say that you would like reconsideration 
because this testing is a covered benefit. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage. 
 
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 DecisionDx Melanoma testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is Stage  T1a without documented concern about adequacy of 
microstaging. 
 
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 DecisionDx Melanoma testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the DecisionDX Melanoma testing provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on May 28, 2021. 
 
You asked the Plan to pay for drug testing. You say that the enrollee had active coverage on this date of service 
and should not be held liable for any charges except contractual obligations. The Plan denied your request. The 
Plan says the denial of payment for this testing is correct, because code G0480 is not supported and this testing 
should be billed with code G0483 instead. 
 
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 G0480 is drug test(s), definitive; qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 1 to 7 drug class(es), including metabolites 
if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the record shows that 25 
drug classes were included in this testing, which is more than 7 drug classes allowable for code G0480. Test code G0483 may be more appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2021. 
 
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 services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies coded as A6199, A6010, A6252, 
A6446, A4450, A6222 and A6219 provided on January 24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee has an approved admission in 
a nursing/rehabilitation facility and as a resident is entitled to receive surgical dressings as a covered benefit 
just as they would under Medicare Part B. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 wound care supplies coded as A6199, A6010, 
A6252, A6446, A4450, A6222 and A6219 provided on January 24, 2022 by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage of a home 
ventilator have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has a diagnosis of COPD, with recent hospitalizations.  
However, there is no arterial blood gases test, done while stable as an outpatient, to confirm CO2 retention.   
 There is no evidence of failure of bipap, with or without average volume-assured pressure support, as an 
outpatient. Medicare does not cover a home ventilator when used as bi-level positive airway pressure. The 
denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded with 81403-90, 81407-90, 
81408-90, 81408-59-90 and 81479-90 provided June 15, 2020. 
 You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the services do not meet Medicare 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded with 81403-90, 81407-90, 81408-90, 
81408-59-90 and 81479-90 provided June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2745, V2781) purchased on 
December 20, 2021, from an out-of-network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that you chose this provider because they offered better 
prices, and you feel that the Plan should cover these services or add this provider to their network to save 
everyone money. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's 
network. Out-of-network services are not covered by your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a provider in the specified vision vendor 
network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified network. 
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2025, V2745, V2781) purchased 
on December 20, 2021, from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve Trulance. The Plan denied your request. The Plan says Trulance is a benefit 
exclusion. The Plan also says that drug coverage is limited only to those drugs covered under your medical 
benefit. 
 
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 Trulance.  
 
Benefits for Trulance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
have impairments in both mobility and activities of daily living and dysphagia; however, occupational and 
speech therapy specifically state that you would be able to receive required therapy in an outpatient setting. Due to recommendations from evaluating therapists you do not meet criteria for an intensive inpatient therapy 
program. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (0275T) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested service is not covered by Medicare or the health 
plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, the enrollee is not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve a minimally 
invasive lumbar decompression (0275T). Therefore, we decided that the Plan does not have to pre-approve 
minimally invasive lumbar decompression (0275T) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been 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 Supartz FX. Our reviewer says that the 
requirements for coverage of Supartz FX have not been met. Our physician reviewer found the Plan requires a 
trial of Durolane, Gelsyn, and Synvisc/SynviscOne before they will approve the requested drug. The enrollee 
has not tried these drugs, and the submitted documentation does not indicate that these drugs would likely be 
less effective or 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.