Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer provided on April 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for nebulizer. You say that you would like to be reimbursed for the purchase of a 
nebulizer. The Plan denied your request. The Plan says they only cover the rental of a nebulizer from an 
approved supplier and will not cover the cost of purchasing one. 
 
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 nebulizer provided on April 18, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. The record shows that the claim was billed with diagnosis code, 
I70.92. This code has a code first note, which means it is a manifestation code and must be sequenced after an 
etiology code. 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 the services provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, nail trimming, and nail debridement provided 
on March 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, the nail trimming, and the nail debridement. You say that the 
enrollee misled the office of incorrect insurance, therefore the office was unable to obtain authorization. The 
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit, the nail trimming, and the nail debridement. We found no exception that would require the Plan to 
pay for the office visit, the nail trimming, and the nail debridement. The records provided for review do not 
show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to 
pay for the office visit, nail trimming, and nail debridement provided on March 17, 2022, by an out-of-network 
(OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321).  
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for coverage of 
the requested service have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of sustained pain relief for at least 3 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62321).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 11, 2022. 
 
You asked the Plan to pay for ambulance services. You say that services were rendered prior to the enrollee 
being admitted to hospice. The Plan denied your request. The Plan says original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on February 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service April 23, 
2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is a service code only. You also say 
that it is not used to bill for drugs or durable medical equipment. The Plan denied your request. The Plan says 
the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service April 23, 2022, to May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
March 1, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract says that hearing aids purchased 
outside of the Plans select hearing aid vendor network are not covered. The hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epidural Steroid Injections. 
 
You asked the Plan to pre-approve the Epidural Steroid Injections. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when there is a History, 
physical examination, and concordant radiological image-based diagnostic testing that supports one of the 
following: Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis OR Post-laminectomy syndrome, OR Acute herpes zoster associated pain. AND 
Radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of life 
or function. 
 
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 Epidural Steroid Injections. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found there is no imaging or 
other objective data, or physical exam findings that supports the diagnosis of radiculopathy. 
 
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 Epidural Steroid Injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Epidural Steroid Injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on September 8, 2021. 
 
You asked the Plan to pay for PrismRA testing. You say that these services were necessary and were performed 
by a Clinical Laboratory Improvement Amendments (CLIA)-certified lab. The Plan denied your request. The 
Plan says this test is not approved by the FDA and therefore is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden (0037U). 
 
You asked the Plan to pre-approve the FoundationOne CDx (F1CDx) test. You say that the enrollee has 
metastatic pancreatic cancer, and the requested testing is medically necessary. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for this test. There was no documentation submitted that 
shows that the enrollee meets the criteria for this test. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the FoundationOne CDx (F1CDx) test have not been met. Specifically, results provided to the 
treating physician for management of the enrollee using a report template was not submitted by the provider. 
Therefore, we decided that the Plan does not have to pre-approve targeted genomic sequence analysis, solid 
organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number 
amplifications, gene rearrangements, microsatellite instability and tumor mutational burden (0037U).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography services coded 77065 provided 
on December 20, 2021. 
 You asked the Plan to pay for the diagnostic mammography services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare billing policy. 
 
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 code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic mammography services have not been met. Therefore, we decided that the Plan does not have to pay 
for the diagnostic mammography services coded 77065 provided on December 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 9, 2020. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care rendered by the out-of-network 
(OON) provider from April 2, 2021, through April 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the inpatient hospital care rendered by the out-of-network (OON) provider from 
April 2, 2021, through April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator 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 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 the portable ventilator. Our reviewer 
says that the requested ventilator is not medically necessary. Our physician reviewer found the records show 
that the enrollee's needs can be met in the outpatient setting using BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 6, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the treating 
physician did not write the order. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show that the lab services in question were 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 the office visit provided on March 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on April 12, 2022. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a ConfirmMDx epigenetic assay 
service, providers should enter the appropriate DEX Z-Code identifier adjacent to the procedure code in the 
comment/narrative field. 
 
We looked at the file and Medicare rules. The testing at issue was not reported with a DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. 
Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on April 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-segmented pneumatic compressor (E0650). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you are appealing the 
denial of your request for coverage of a compression sleeve and compression gauntlet, both of which were 
prescribed for you as a preventive measure for lymphedema. The Plan denied your request. The Plan says the 
clinical documentation provided does not support medical necessity. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of breast cancer status post treatment. A 
request was made for a compression sleeve and compression gauntlet to help prevent lymphedema. The Plan 
denied a pneumatic compression device, however, the provided notes did not clearly show that the pneumatic 
device was actually requested or intended to be requested. There appears to have been an error in regards to 
this. The compression sleeve and gauntlet is part of a conservative approach to prevent lymphedema and should 
be covered as requested. However, the pneumatic compression device is not supported for coverage for this 
enrollee and appears to not have been requested in the first place. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a non-segmented pneumatic compressor (E0650).