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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81162, 81301, 
81311, 81292, 81295, 81298, 81317, 81194, and 81309) provided on June 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 laboratory services have not been met. For CPT code(s): 81206, 
81162, 81301, and 81311; the denial remains upheld as non-covered as Medicare denies coverage when a 
laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of 
the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the 
panel. 
 
CPT code(s): 81292, 81295, 81298, 81317, 81194, and 81309, remain not supported. The place of service on 
the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an inpatient 
hospital setting POS 21. Also, the laboratory results submitted indicate the specimen was collected on May 18, 
2021, and received by the lab on May 22, 2021. Therefore, the billed code cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81162, 81301, 81311, 81292, 
81295, 81298, 81317, 81194, and 81309) provided on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 is not a network provider with the Plan. The Plan has network providers available who 
can provide the service at issue in this appeal.  We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine to be rendered by 
the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the prosthesis and components for the right residual limb. 
 
You asked the Plan to pre-approve the prosthesis and components. You say that the items are medically 
necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 prosthesis and components. Our 
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a wound documented on the left residual limb however this will not affect 
fitting and placement of right sided prosthesis and surgery documentation states that you were previously at a 
K2 level with good healing of right residual limb in March of 2022, thus the requested items would be 
necessary to return you to prior functional level. 
 
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 prosthesis and components have been met. Therefore, we decided that the 
Plan has to pre-approve the prosthesis and components for the right residual limb.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrolee has osteoporosis. She has 
not tired and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Prolia is 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 Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on 
August 24, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 laboratory service have not been met. CPT code 0242U 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was collected on August 17, 2021 and received by the lab on August 18, 2021. Of note, the 
patient resides in Georgia, and the billing laboratory is located in Illinois; therefore, the billed code cannot be 
verified. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) 
provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 
99239) provided to the enrollee on February 16, 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 Current Procedural Terminology (CPT) code 99239 remains not supported. 
 
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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found based on the medical records 
provided, there is documentation that hospital discharge day management was rendered in this case; however, 
records do not document that at least 31 minutes were spent on the discharge management.  
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge day management services (procedure code 99239) provided to the enrollee 
on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery (E1399). 
 
You asked the Plan to pre-approve a back-up battery. You say that you need this for your continuous positive 
airway pressure device due to power outages. The Plan denied your request. The Plan says this item is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pre-approve a back-up battery (E1399).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced foot and ankle system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is able to ambulate at a K3 
level. The Plan denied your request. The Plan says that the requested foot exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
The file shows that an advanced (K3) foot and ankle system were requested (codes L5981 and L5986). 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 services. Our physician 
reviewer found that the enrollee has a relevant past medical history of a left below the knee amputation with 
prosthesis. Provider documentation clearly states advanced function of the enrollee. The skilled therapist 
documents that the enrollee is doing well with variable cadence over multiple types of terrain. An assistive 
device was only required for a short period of time related to fall and was not further required. A review of the 
records show that the enrollee meets K3 level criteria based on clinical documentation provided. Therefore, a 
K3 level foot would be 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an advanced foot and ankle system.  
 
 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on September 27, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. The Plan denied 
your request. The Plan says these services are not eligible for payment. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and 
ground mileage. Our reviewer says that the documentation does not support that the ambulance transport on 
September 27, 2021 was medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollees presenting symptoms did not meet prudent layperson criteria for emergency care. Our reviewer 
found that the documentation does not support that other means of transport (such as stretcher van, wheelchair 
van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on September 27, 2021. 
Transportation by private vehicle would have been medically appropriate. The documentation does not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide for safe transport. There were no acutely abnormal physical exam findings 
and vital signs were stable. Our physician reviewer also found that the enrollee was transported to the nearest 
reasonable receiving 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 emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation 
(A0429) and ground mileage (A0425) provided on September 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0299) provided on 
November 1, 2021, to January 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON home health services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says there is no referral or authorization on file for these 
services. Out-of-network care is only covered when the services provided are urgent/emergent or pre-approved. 
 
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 home health services (G0151, G0299) provided on 
November 1, 2021, to January 7, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require this 
transportation. The Plan denied your request. The Plan says that each trip must not exceed 50 miles. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (97110), therapeutic activities 
(97530), and manual therapy techniques (97140) provided on July 16, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the rehabilitation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says no prior authorization for the tests were obtained. The Plan also 
says there was no documentation that the test was part of an emergency service. 
 
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 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 therapeutic procedure (97110), therapeutic 
activities (97530), and manual therapy techniques (97140) provided on July 16, 2021 by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82565) provided on September 13, 
2021. 
 
You asked the Plan to pay for code 82565. 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. In this case, we have confirmed that code 82565 
is a column II code to column I code 80053. 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 laboratory services (82565) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The 
Plan denied your request. The Plan says this does not meet the statutory definition of a surgical dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0669) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that you are 
aware that there is an in network provider that supplies lymphedema pump but the doctor has ordered this 
brand lymphedema pump and this provider is the only supplier in the enrollee's geographical area. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 
a pneumatic compression device (E0651) and segmental pneumatic appliance (E0669) to be provided by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport (A0431), and air mileage 
(A0436) provided on September 21, 2021. 
 You asked the Plan to pay for the air ambulance services. You say that the transport meets the medical 
necessity guidelines. The Plan denied your request. The Plan says the air ambulance services were not 
medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the 
documentation did support that the enrollee suffered from an illness or injury that contraindicated 
transportation by any means other than ambulance. The documentation did not support that the enrollee's 
condition was such that the time needed to transport a patient by ground, or the instability of transportation by 
ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The reviewer also 
found that the documentation did support that the transferring hospital did not have adequate facilities to 
provide the medical services needed by 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance transport (A0431), and air mileage (A0436) provided on 
September 21, 2021.