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

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips. 
 
You asked the Plan to pre-approve Accu-Chek test strips. You say that you would like reconsideration because 
the Accu-check test strips are medically necessary. The Plan denied your request. The Plan says this is not the 
preferred brand of diabetic supplies. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 Accu-Chek test strips. Our reviewer 
says that the non-preferred brand is not medically reasonable and necessary in this case. Our physician 
reviewer found there is no reason given in the notes to support that you require the non-preferred brand of test 
strips and meter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Accu-Chek test strips.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Alimta (J9305). 
 
You asked the Plan to pre-approve Alimta. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this drug is not medically reasonable and necessary. 
 
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 Alimta. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with metastatic adenocarcinoma of the lung. In this case, per the National Comprehensive Cancer 
Network Compendia the use of Alimta in combination with Carboplatin is approved for coverage for the 
enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan has to pre-
approve Alimta (J9305).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services provided on July 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 45380 is colonoscopy, flexible; with biopsy, single or 
multiple. We find that CPT code 45380 was billed with code 45385. CPT code 45380 may be eligible for 
payment when billed with this code pair. The claim information does not show that CPT code 45380 was billed 
with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
colonoscopy services provided on July 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on August 17, 2021. 
 
You asked the Plan to pay for ambulance transport. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
ambulance services used for transportation of a hospital inpatient to another facility is considered part of the 
inpatient admission and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation from a facility where 
the patient is an inpatient to another hospital or facility is covered under Part A by the prospective payment rate 
or as reasonable costs to hospitals excluded from the prospective payment system.  
 
 
 We looked at the file and Medicare rules. This transportation from a hospital where the enrollee was an 
inpatient to another facility is covered under the Part A payment made to the hospital facility, so is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of ambulance 
transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
transportation provided on August 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant care services (S5125). 
 
You asked the Plan to pre-approve attendant care services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says the requested care is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of attendant care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
attendant care services (S5125).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 6, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services provided on July 6, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a DyAnsys electro-acupuncture device. 
 
You asked the Plan to pre-approve electro-acupuncture device. You say that the enrollee needs this to help with 
chronic pain. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices are not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a DyAnsys electro-acupuncture device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on May 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on May 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on January 1, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service 
was previously paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 71046 is radiologic examination, chest; 2 views. We find 
that CPT code 71046 was previously billed and paid for by the Plan. The records provided do not indicate that 
additional testing was provided on the date of service at issue. 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 chest x-ray provided on January 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene sequencing services provided on June 7, 2021. 
 
You asked the Plan to pay for the billed services. You say that treatment sought was a covered service. The 
Plan denied your request. The Plan says there are no modifiers allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that CPT codes 81295 and 81298 were billed with code 81432. 
These codes have a modifier indicator of 0. This means that codes 81295 and 81298 are not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the gene sequencing services 
provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on September 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a limb compression device provided on 
June 2, 2021. 
 
You asked the Plan to waive the coinsurance for the compression device. You say that the price is too high as 
you can purchase the same device online for a fraction of the cost. The Plan denied your request. The Plan says 
the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) items and related supplies.  
 
 
 
 
 
 You have been asked to pay $850, which is 20% of the allowed amount for the compression device ($4,250 
allowed amount x 20% coinsurance = $850). The compression device falls within the Durable Medical 
Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a limb compression device provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you only require short-term additional acute 
care services that can safely be administered at the current facility. You do not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 17, 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 an appropriate modifier was not billed in this case. 
 
 
 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 64445 
is a column II code to column I code 01232. 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 surgical services provided to the enrollee on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 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 genetic testing provided on April 5, 
2021, have been met. We find that payment for the lab services is not supported in the medical record. We find 
that the issue of intent is not clear. There are no medical records in the case file in regard to the physicians 
intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on April 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Infectious disease (bacterial or viral respiratory tract 
infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as 
detected or not detected (0202U) and the Albuterol (J7613) provided from September 18, 2021, to September 
20, 2021. 
 
You asked the Plan to pay for codes 0202U and J7613. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says that code 0202U is not covered. Also, code J7613 has 
a status indicator of E under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate 
payment is made for this code. Therefore, we decided that the Plan does not have to pay for the Infectious 
disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets 
including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, 
nasopharyngeal swab, each pathogen reported as detected or not detected (0202U) and the Albuterol (J7613) 
provided from September 18, 2021, to September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS) 
(L8679). 
 
You asked the Plan to pre-approve the PENS unit. You say that please see attached letter and supporting 
documentation proving medical necessity for this prior authorization request. The Plan denied your request. 
The Plan says it was determined by the provider given the information provided that the enrollee would be an 
excellent candidate for the PENS unit to help with chronic pain and reduce the use of narcotics. 
 
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 PENS unit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the requirements listed in 
the National Coverage Determination (NCD): Electrical Nerve Stimulators (160.7) have been met for Medicare 
coverage of the requested implantable neurostimulator. Records do not document that the enrollee has 
undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation, 
including psychological as well as physical evaluation. 
 
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 PENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous electrical nerve stimulation (PENS) (L8679).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Introduction of needle or intracatheter (36000) and the 
Ultrasound guidance for vascular access (76937) provided on May 18, 2021. 
 
You asked the Plan to pay for codes 36000 and 76937. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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.  
 
We looked at the file and Medicare rules. Code 36000 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. We have also confirmed 
that code 76937 is an add-on code and as the primary code 36000 is not payable, the add-on code is not eligible 
for separate payment. 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 Introduction of needle or intracatheter (36000) and the 
Ultrasound guidance for vascular access (76937) provided on May 18, 2021.