Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the single vision lenses, and the delivery set up 
provided by an out-of-network on November 11, 2022. 
 
You asked the Plan to pay for the frames, the single vision lenses, and the delivery set up. You say that your 
deductible had already been met at the time of the service. The Plan denied your request. The Plan says the 
benefit limit has been exceeded. 
 
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 up to a $515 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid a total of $515 on July 13, 2022, and 
November 12, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules 
for coverage of the frames, the single vision lenses, and the delivery set up have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames, the single vision lenses, and the delivery set up 
provided by an out-of-network on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve the Freestyle Libre 2. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 87481, 
87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798) 
provided on June 15, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 
87661, 87798) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor-controlled knee (MPK) for a 
prosthetic leg. 
 
You asked the Plan to pre-approve the requested MPK. You say that it is felt that you require this specific type 
of knee. The Plan denied your request. The Plan says you do not meet the criteria for the requested knee. 
 
The Plan follows Medicare rules. Medicare rules say that an MPK may be covered for enrollees with a 
functional level of 3 or above. 
 
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 requested MPK.  Our reviewer says that the documentation does not support that the requested MPK is reasonable and 
necessary. Our physician reviewer found the enrollee underwent a below-the-knee amputation of the right leg 
in 2021. He walks with a walker and is able to walk outside with a slow cadence. He is able to walk on uneven 
ground. The enrollee is a limited community ambulator two years after his amputation. He does not have an 
activity level consistent with a level 3 ambulator. 
 
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 requested MPK have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a microprocessor-controlled knee (MPK) for a prosthetic leg.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you have wounds that you need help with. The Plan 
denied your request. The Plan says the requested SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic surface brachytherapy. 
 
You asked the Plan to pre-approve electronic surface brachytherapy. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 electronic surface brachytherapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there are no 
compelling reasons offered for why SRT would be needed over more standard approaches of radiation 
delivery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic surface brachytherapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electronic surface brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69210 billed for date of service December 9, 
2022. 
 
You asked the Plan to pay for procedure code 69210. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 69210 is bundled into payment for code 92567.  
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 69210 
is a column II code to column I code 92567. 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 69210 billed for date of service December 9, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82607) provided on August 31, 2022. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab 
services (82607) provided on August 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion medication and services provided on 
November 4, 2020. 
 
You asked the Plan to pay for the intravenous infusion medication and services. You say that you would like 
this claim to be reconsidered for medical necessity. The Plan denied your request. The Plan says the claim was 
received on November 29, 2022. The Plan also says this claim was processed and denied for untimely filing of 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for the intravenous infusion medication and services was not filed until 
November 29, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the intravenous infusion 
medication and services provided on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 laboratory services provided on August 17, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0315U) provided on October 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 lab services (0315U) provided on 
October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the services are medically necessary. The Plan denied your request. The Plan says you 
do not have out-of-network benefits unless the Plan is unable to render necessary medical services with 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega 3. 
 
You asked the Plan to pre-approve Kerecis Omega 3. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Kerecis Omega 3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Kerecis Omega 3 is unproven and not medically necessary for any indication due to 
insufficient evidence of efficacy. The review has determined that the items/services at issue in this case are 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 Kerecis Omega 3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer purchased on December 31, 2022. 
 
You asked the Plan to pay for the nebulizer. You say that you like to have a nebulizer, especially in the winter, 
to help with your dry cough. You also say that you realize it is not listed on the Pick Your Perks list, but you 
would appreciate if this could be considered for reimbursement. The Plan denied your request. The Plan says 
per your Pick Your Perks benefit, nebulizers are not a reimbursable item. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
nebulizer is an OTC item. However, the Plan offers a Pick Your Perks benefit that exceeds Medicare coverage. 
For that reason, the Plans coverage rules apply in this case. Specifically, a nebulizer is not listed as a covered 
item under the Pick Your Perks benefit. Therefore, we decided that the Plan does not have to pay for the 
nebulizer purchased on December 31, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening for abdominal aortic aneurysm 
(AAA) (76706-26) provided on October 3, 2022. 
 
You asked the Plan to pay for the service. You say that the procedure was performed at the request of the 
referring doctor and is medically necessary The Plan denied your request. The Plan says the enrollee did not 
meet criteria. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Review of the claim this was billed 
with diagnosis code I48.91 (Unspecified atrial fibrillation) which does not indicate the Centers for Medicare & 
Medicaid Services (CMS) criteria of a family history of abdominal aortic aneurysm, a man aged 65 to 75 who 
has smoked at least 100 cigarettes in the enrollee's lifetime, or other risk factors recommended by the United 
States Preventive Services Task Force. Also, documentation received does not indicate that the enrollee 
received the screening study for one of the CMS risk categories of a family history of abdominal aortic 
aneurysm, a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime, or other risk factors 
recommended by the United States Preventive Services Task Force. Therefore, we decided that the Plan does 
not have to pay for the ultrasound screening for abdominal aortic aneurysm (AAA) (76706-26) provided on 
October 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on October 15, 2022. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 95800 is sleep study, unattended, simultaneous recording; 
heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time. 
 
We asked our coder 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 services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the procedure report documents a type 3 
multi-channel overnight portable sleep study was performed. In this case, a more appropriate code should be reported to support service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 10, 2022. 
Therefore, we decided that the Plan does not have to pre-approve upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided from 
August 18, 2022, through September 8, 2022. 
 
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 are not payable as they were 
rendered by an ineligible provider. 
 
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. 
 
A 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 acupuncture treatments (97810, 
97811) provided from August 18, 2022, through September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast cancer 1 and 2 (e.g., hereditary breast and ovarian 
cancer) gene analysis (81162) provided November 3, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered genetic testing 
for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The 
Plan says the provided test is not covered by Medicare. 
 
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 records show that the enrollee does not have a personal history 
of cancer and presented for a hereditary risk evaluation. 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 the breast cancer 1 and 2 (e.g., hereditary breast and ovarian cancer) gene analysis (81162) provided 
November 3, 2022.