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

 
We decided that the Plan does not have to pay for an office visit, electrical stimulation and mechanical traction 
provided from October 26, 2021, through November 29, 2021. 
 
You asked the Plan to pay for an office visit, electrical stimulation and mechanical traction. You say that these 
chiropractic services have improved your quality of life immensely where nothing else has helped. The Plan 
denied your request. The Plan says the only covered chiropractic service is manual manipulation of the spine to 
correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit, electrical stimulation and mechanical traction provided from 
October 26, 2021, through November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
November 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx meets the 
requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 
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 next generation sequence testing (NGS) testing panel 
performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is 
statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. 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 
FoundationOne CDx (F1CDx) test (0037U) provided November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing related to end-stage renal disease (ESRD) 
provided on January 17, 2022. 
 
You asked the Plan to pay for the ESRD lab testing. You say that this testing should not be bundled with 
facility payment. The Plan denied your request. The Plan says these tests should be billed to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing related to end-stage renal disease (ESRD) provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on November 23, 2021. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the vision benefit is 
not covered if the services are not purchased through the Plan vision. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when purchased from a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear was not purchased from a Plan 
vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on 
November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multidrug panel of definitive (confirmation) urine drug tests that are not used in 
management of the enrollee is 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the enrollee's diagnosis is medication management of long 
term (current) drug therapy. The medical record sent by the provider shows very limited presumptive screening 
test results which are inconsistent with prescription medications, or history and expected results. Definitive 
confirmation testing was medically necessary for only 1 drug class: Barbiturates. The review has determined 
that the enrollee does not meet the criteria for this testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on December 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided on December 9, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the NPI registry shows this provider is certified 
and able to perform anesthesia. The Plan denied your request. The Plan says that the Plan only reimburses to 
anesthesia providers. 
 
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. The Plan has not provided documentation to support their denial. Therefore, we 
decided that the Plan has to pay for anesthesia services provided on December 9, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 15, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that procedure code 87507 is covered in beneficiaries with 
immunodeficiency and/or critical illness. 
 
We looked at the file and Medicare rules. The file does not show that the enrollee had immunodeficiency 
and/or critical illness. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on December 15, 2021.  
 
LCA A56711 referenced by the Plan is currently retired but was valid for the date of service at issue and was 
used in the MAXIMUS determination.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) and related supplies provided 
on December 27, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that the records support that payment should be 
made. The Plan denied your request. The Plan says that this claim was denied due to insufficient information. 
 
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. The Plan's denial stated that there was not sufficient information to justify 
payment. However, the appeal request was submitted with a valid order, medical records , and proof of 
delivery. The records support that criteria for the CGM are met. We find the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) and related supplies 
provided on December 27, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve a VIA Disc allograft intervertebral disc augmentation procedure. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that TIPs are covered when specific criteria are met. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to establish 
long-term support for the use of VIA disc. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for 
VIA Disc allograft intervertebral disc augmentation procedure is not medically reasonable or 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 a VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services provided on 
November 10, 2021. 
 
You asked the Plan to pay for subsequent hospital care services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 subsequent hospital care services provided on  
November 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve anesthesia services (00860) provided on October 19, 2021. 
 
You asked the Plan to pre-approve anesthesia services. You say that the services at issue were coded correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan has not explained why an anesthetist was or would have 
been incapable of providing the services at issue. It is the Plan's responsibility to substantiate its denial. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pre-approve anesthesia services (00860) provided on October 19, 2021.  
 
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 the standard wheelchair (K0001) purchased September 24, 
2021. 
 
You asked the Plan to pay for the wheelchair. You say that you are appealing the denial of reimbursement for 
the wheelchair you purchased. The Plan denied your request. The Plan says if you go to a provider who is not 
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the standard wheelchair (K0001) 
purchased September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telemedicine consultation provided on January 22, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telemedicine consultation. You say that the service was medically necessary 
because the enrollee was in pain and needed to discuss getting imaging on her hip. 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 
telemedicine consultation. We found no exception that would require the Plan to pay for telemedicine 
consultation. 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 telemedicine consultation provided on January 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on October 15, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says this service 
does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National 
Coverage Determination (NCD). Related services performed in connection with the denied procedure are also 
not covered. 
 
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 
service 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 anesthesia services provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided December 22, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was non-covered as of the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage for CxBladder was reaffirmed. 
 
We looked at the file and Medicare rules. The genetic testing performed was not covered under Medicare rules 
as of the date of service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) 
provided December 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on January 25, 2022. 
 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 separately payable. 
 
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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound rendered on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair ramp you purchased on December 20, 2021. 
 
You asked the Plan to pay for the wheelchair ramp. You say that you need this ramp so that you get into and 
out of your home. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the wheelchair ramp you purchased on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on October 12, 2021. 
 
You asked the Plan to pay for hearing aids. You say that you were not told that the provider was out-of-
network. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan hearing 
provider to be covered under the hearing aid services offered by the members Plan. 
 
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. The Plan pays for 
hearing aids only when ordered through the Plan hearing provider.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture procedures provided from October 20, 2020, 
through November 3, 2020. 
 
You asked the Plan to pay for acupuncture procedures. The Plan denied your request. The Plan says 
acupuncture is not a covered service. 
 
The Plan contract does not cover acupuncture.  
 
We looked at the file and the Plans rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan contract says acupuncture services are not 
covered under any condition. Therefore, we decided that the Plan does not have to pay for acupuncture 
procedures provided from October 20, 2020, through November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical pathology services provided on March 15, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical pathology 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 it was determined these services were not urgent or emergent. 
 
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 Surgical pathology services provided on March 
15, 2022 by an out-of-network (OON) provider.