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

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on February 8, 
2022. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that you have provided medical records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is inclusive to another 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, 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 an abdominal ultrasound (76705) provided on February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on February 3, 
2022. 
 You asked the Plan to pay for an abdominal ultrasound. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
service at issue is inclusive to another 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, we have confirmed that code 76700 
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 an abdominal ultrasound (76700) provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on February 
1, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with a 
place of service of 22 (outpatient hospital). this code may not be paid if furnished to hospital outpatients or 
non-hospital enrollees. Based on this information, we decided that Medicare rules for coverage of the blood 
smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
services coded 85060 provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lumex Walkabout Contour Deluxe rollator with 
seat. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation to support the need for a specific brand. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.   
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have previously been authorized for an in-network walker with a seat. There is no indication why the 
brand-named rollator would be medically necessary over the previously authorized walker. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Lumex Walkabout Contour Deluxe rollator with seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical pathology provided on February 14, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Surgical pathology. 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 provided on February 14, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening cytopathology, cervical or vaginal (any reporting 
system), collected in preservative fluid, automated thin layer preparation, with screening by automated system 
and manual rescreening under physician supervision (G0145) provided December 21, 2021. 
 
You asked the Plan to pay for the screening services. You say that per review with the enrollee's medical 
records, you have not billed this CPT code or diagnosis code in the last two years. Please review and reconsider. The Plan denied your request. The Plan says the information submitted does not support this many 
frequency of services. 
 
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. 
 
Only one interpretation of a screening Papanicolaou test is allowed within a two year period (23 months have 
elapsed) for patients at low risk. The records show that similar Papanicolaou screening services was previously 
provided December 7, 2020. Therefore, we decided that the Plan does not have to pay for screening 
cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer 
preparation, with screening by automated system and manual rescreening under physician supervision (G0145) 
provided December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on October 19, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was necessary to determine a course of 
treatment. The Plan denied your request. The Plan says the testing is not a Medicare benefit. 
 
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 FoundationOne gene panel provided included the FANCC gene. 
Panels of tests that include this gene is statutorily excluded from service. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the gene panel provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial 
of any two of their preferred drugs, Humira, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, 
Orencia, and Enebrel, before they will approve the requested drug. The records do not show that the enrollee 
has failed two of these drugs. The records also do not show that these drugs would like be less effective or have 
adverse effect 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on January 19, 
2022. 
 You asked the Plan to pay for an abdominal ultrasound. You say that you have provided medical records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is inclusive to another 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, 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 an abdominal ultrasound (76705) provided on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy and Opdivo. 
 
You asked the Plan to pre-approve Yervoy and Opdivo. You say that these drugs are medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Yervoy and Opdivo. Our reviewer says 
that the requested drugs are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has been diagnosed with metastatic basal cell carcinoma. They have progressed on prior lines of therapy 
including Immuno-oncology therapy which she is on. In this case, Yervoy and Opdivo are not FDA-approved 
for the enrollee's diagnosis. Furthermore, the use of Yervoy and Opdivo is not supported by one of the major 
drug compendia or by clinical research that appears in a Medicare-approved medical journal. There is no data 
for patients after progression on immunotherapy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy and Opdivo.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided January 7, 2022. 
 
You asked the Plan to pay for the emergency services. You say that [Enter appellant's argument from appeal 
letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says that medicare does not cover 
services that are not performed by a Medicare certified provider. 
 
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 information to substantiate their reason to deny. The 
provider has provided the Medicare temporary hospital enrollment letter which shows enrollment as of May 18, 
2020, which is prior to this date of service. Therefore, we decided that the Plan has to pay for the emergency 
room services provided January 7, 2022.  
 
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 an Orion microprocessor knee for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show an irreparable damage to the current knee, or a change in 
physiologic function. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has been authorized for a replacement socket and has K3 components in his prosthesis that 
are in good condition. There is no indication that he requires a microprocessor knee. 
 
 
 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an Orion microprocessor knee for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this appeal seeks to recover charges for 
medically necessary services rendered by the facility as supported by the enclosed medical records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were 
not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 January 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on February 
15, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99152). You say that the claim was denied for 
procedure codes 99152 and 64635. You say that you submitted medical records for review. The Plan denied 
your request. The Plan says CPT code 64635 has already been paid. The Plan also says CPT code 99152 
remains denied as the documentation submitted did not indicate the presence of an independent trained 
observer. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
  We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not 
support the presence of a trained observer as required by the CPT code billed. Based on this information, we 
decided that Medicare rules for coverage of the moderate sedation services (99152) have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on February 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70480) provided on January 25, 2022. 
  You asked the Plan to pay for the CT scan (70480). You say that the patient had multiple exams on this date of 
service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
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 70480 
is a column II code to column I code 70450. 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 CT scan (70480) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional acupuncture sessions. 
 
You asked the Plan to pre-approve eight (8) additional acupuncture sessions. You say that eight (8) additional 
acupuncture sessions are medically necessary. The Plan denied your request. The Plan says the records 
provided are not within the range for the dates of the requested treatment. Clinician review indicated the exam 
findings and provided records do not support the request. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 eight (8) additional acupuncture sessions. Our reviewer says that additional acupuncture sessions are not medically necessary. Our physician 
reviewer found that you were treated with acupuncture (27 sessions in 2021 and 15 sessions so far in 2022).  
Medicare coverage allows only up to 20 sessions per year with evidence of benefit. However, the provided 
documentation did not clearly show benefit from recent sessions and this request for 8 sessions would surpass 
the 20-session limit for this year. Therefore, this patient does not meet the Medicare criteria for this request for 
acupuncture.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight (8) additional acupuncture sessions have not been met. Therefore, we 
decided that the Plan does not have to pre-approve eight (8) additional acupuncture sessions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan (CPT code J9312). 
 You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug would be deemed a routine cost covered by the Medicare 
Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the medication as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Rituxan (CPT code J9312).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hizentra 10GM/50ML vial. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee must have tried and failed Gamunex-C or have a medical reason they 
cannot use it. The Plan states the enrollee's practitioner did not submit documentation that the enrollee meets 
these criteria. 
 
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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hizentra 10GM/50ML vial.