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

 
We decided that the Plan does not have to pay for the lab testing services provided on February 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that you continue to get statements from the lab. 
The Plan denied your request. The Plan says the claims processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. The record indicates that the Plan has paid the Medicare Allowed 
Amount for the services at issue. A Medicare provider should accept the Medicare Allowed Amount as 
payment in full. After looking at all of the information in this case, we found that you do not owe any money. If 
the provider has billed you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly. The Plan is not responsible for paying the balance that remains after the Medicare allowed payment. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on February 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says medical records were 
not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the services provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services and treatment to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 the office 
services and treatment to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Hyalgan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the Plan's required drugs would likely 
be less effective and/or likely 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for a shoulder arthroscopy 
surgery (29826, 29827, 29999) provided on May 26, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for a 
shoulder arthroscopy surgery (29826, 29827, 29999) provided on May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27280) with inpatient admission 
for the surgery. 
 
You asked the Plan to pre-approve sacroiliac joint fusion and inpatient admission. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
services are 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 pre-approve sacroiliac joint fusion and inpatient 
admission. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the enrollee has degenerative back pain. There is no sacroiliac 
joint instability, fracture or lesion. Sacroiliac joint fusion is experimental for degenerative back pain. More 
research is needed to demonstrate the safety and effectiveness of the requested treatment. Because sacroiliac 
joint fusion is not medically necessary, inpatient admission is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint fusion and inpatient admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint fusion (27280) with inpatient admission for 
the surgery.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice when the services were provided. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61783 billed for date of service July 20, 
2022. 
 
You asked the Plan to pay for procedure code 61783. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says payment for code 61783 is bundled into payment 
for code 63052. 
 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 61783 
is a column II code to column I code 63052. 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 procedure code 61783 billed for date of service July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the EOB must be 
received from the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
primary insurer and informed the primary insurer that an EOB is needed. As the secondary insurer, the Plan 
cannot be held responsible for the services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the services provided on February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the member does not meet the Medicare 
criteria for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that patient has multiple active comorbidities (elevated BP, edema, 
dizziness related to chronic comorbidities thus acute management per documentation has been completed) thus 
continued inpatient hospitalization during rehabilitation would be required. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power tilt and recline, power elevating leg rests, and 
combination skin protection and positioning seat cushion for a wheelchair. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that your functional 
status allows you to weight shift as needed. You do not have impaired flexing of the knees, swelling from 
excessive fluid (edema), spasticity, or reliance on intermittent catheterization. You do not have any postural 
issues. The criteria for coverage are not met and the services are therefore 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 a power tilt and recline, power elevating leg rests, and combination skin protection and 
positioning seat cushion for a wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Carotid Sinus Baroreflex Activation Device (0266T). 
 
You asked the Plan to pre-approve the Carotid Sinus Baroreflex Activation Device. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the requested service is experimental and is 
non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Carotid Sinus Baroreflex Activation 
Device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the evidence is insufficient to determine the effects of the technology 
on health outcomes. More research is needed to show safety and efficacy. 
 
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 Carotid Sinus Baroreflex Activation Device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Carotid Sinus Baroreflex Activation Device (0266T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on May 10, 
2022. 
 
You asked the Plan to pay for the Cxbladder Detect testing. You say that this test was medically necessary and 
is covered. 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 Cxbladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on May 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate rental (E1390) and a portable 
oxygen concentrator, rental (E1392). 
 
You asked the Plan to pre-approve rental of an oxygen concentrator and a portable oxygen concentrator. You 
say that the enrollee has been on oxygen since 2019. He began with one company and then changed to a new 
company in December 2021. The Plan denied your request. The Plan says Medicare rules state oxygen 
equipment is limited to 36 months of rental. After 36 months, the vendor is required to provide contents and 
service for months 37-60 months. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for oxygen 
equipment is 5 years. Reimbursement for oxygen equipment is limited to 36 monthly rental payments 
 
We looked at the file and Medicare rules. The records show that the enrollee has been using oxygen since 
January 2019. The enrollee has had oxygen for over 36 months and the provider can no longer bill for the 
rentals. Based on this information, we decided that Medicare rules for coverage of rental of an oxygen 
concentrator and a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an oxygen concentrator, single delivery port, capable of delivering 85 percent or 
greater oxygen concentration at the prescribed flow rate rental (E1390) and a portable oxygen concentrator, 
rental (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the CardioMEMS device is considered unproven and 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 pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RhinAer procedure. 
 
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 services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
inflammation of the nasal passages (vasomotor and allergic rhinitis). There is insufficient medical literature to 
support the safety and effectiveness of the requested RhinAer procedure. The services are 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 a RhinAer procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 29, 
2022. 
 You asked the Plan to pay for procedure code 72170. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 72170 is bundled into payment for 
code 72190. 
 
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 72170 
is a column II code to column I code 72190. 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 procedure code 72170 billed for date of service June 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to dialysis. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per 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 50 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 trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xT testing provided on April 19, 2022.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are 
not met. 
 
The Plan follows Medicare rules. Medicare rules say that NGS is covered for the indications established in the 
applicable NCD. 
 
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 testing. Our reviewer says that the 
requested testing was not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee does not have documented advanced, metastatic, or refractory disease. The review has determined 
that the requested testing was not medically reasonable or necessary according to the coverage criteria 
established in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for Tempus xT testing provided on April 19, 2022.