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

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2, glucose monitoring system 
(95250). 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that the records provided support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee is on a fixed 
insulin dose twice a day and is not adjusting insulin doses based on blood glucose readings. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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 the Freestyle Libre 2, glucose monitoring 
system (95250).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided on 
March 7, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you have severe dense 
breasts and were told that a breast ultrasound is a necessary additional test to ascertain breast health. The Plan 
denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $60 
copayment for Medicare-covered x-ray and ultrasounds for Outpatient hospital services.  
 
You have been asked to pay a $60 copayment for the breast ultrasound. The breast ultrasound falls within the 
Outpatient hospital services 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 copayment for the breast ultrasound (76641) 
provided on March 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of cranial cavity contrast 
material (70850) provided on February 28, 2022. 
 
You asked the Plan to pay for the CT of cranial cavity. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70450 and 70480. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 computed tomography (CT) of cranial cavity contrast material 
(70850) provided on February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Th provided documentation does not indicate that the oral anti-emetic will be administered 
within 2 hours of chemotherapy treatment administration. Therefore, we decided that the Plan does not have to 
pre-approve Promethazine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 
24, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment 
for code 70496-26 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intravenous (IV) infusions provided from 
March 3, 2021, to April 13, 2021.  
 
You asked the Plan to waive the copayment for IV infusions. You say that you were never told you would have 
a copayment for each visit. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $100 
copayment for all other in-network outpatient hospital services.  
 
You have been asked to pay a $100 copayment for each IV infusion from March 3, 2021, to April 13, 2021. IV 
infusions fall within the Outpatient Hospital Services 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 
copayment for intravenous (IV) infusions provided from March 3, 2021, to April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu for the enrollee. 
 
You asked the Plan to pre-approve Enhertu. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no citations in the accepted Medicare approved compendia for the use of 
this drug in HER-2 negative metastatic breast cancer. 
 
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 Enhertu. Our reviewer says that 
Enhertu is not medically reasonable and necessary. The enrollee has a diagnosis of HEr2 negative metastatic 
breast cancer. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. There is no literature from Medicare approved 
cancer journals submitted for review. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of Enhertu.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation does not support that you perform blood glucose 
testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) and 
ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment 
program; comprehensive, new patient, 1 or more visits (92004) provided on November 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye refraction and medical eye exam. You say that your eye exam has always 
been paid in previous years. The Plan denied your request. The Plan says these services are not covered when 
provided OON. 
 
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. 
Additionally, the provider has billed for a medical eye exam. The eye refraction is only covered when billed as 
part of a routine eye exam.  Therefore, we decided that the Plan does not have to pay for the determination of 
refractive state (92015) and ophthalmological services: medical examination and evaluation with initiation of 
diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on 
November 21, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional x-ray services provided to the enrollee on December 15, 
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 that the records submitted do not indicate that two separate services were performed/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 71045 is [*****enter CPT Codebook definition*****]. 
 
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 supported by the medical records. Our reviewer found two separate single view chest x-rays 
were done for the enrollee on 12/15/21. They were signed at two different times. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
additional x-ray services provided to the enrollee on December 15, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT code 81162). 
 
You asked the Plan to pre-approve the laboratory services. You say that the services are necessary. The Plan 
denied your request. The Plan says Medicare does not cover BRCA genetic testing if you do not have a 
personal history of breast, ovarian, or pancreatic cancer. It's considered to be screening and is specifically 
excluded by Medicare. 
 
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 enrollee has no personal history of breast, ovarian, or pancreatic cancer. There is no documentation of any 
signs or symptoms of cancer. Medicare does not cover BRCA genetic testing if you do not have a personal 
history of breast, ovarian, or pancreatic cancer. It's considered to be screening and is specifically excluded by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair 
associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 
full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT 
code 81162).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70554 billed for date of service January 11, 
2022. 
 You asked the Plan to pay for procedure code 70554. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70554 
is a column II code to column I code 70551. 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 70554 billed for date of service January 11, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that the 
documentation does not support that Our physician reviewer found you have a diagnosis of anemia of chronic 
kidney disease.  The record indicates that you have hemoglobin values above 10 g/dl, including most recently a 
level of 11.3 g/dl. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition; however, the record provided does not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested drug. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
September 14, 2021, through January 14, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that the cost share is 
incorrect. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
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 $295 
copayment for outpatient hospital services.  
 
You have been asked to pay a $295 copayment for the outpatient hospital services. This service falls within the 
outpatient hospital services 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 copayment for the 
outpatient hospital services provided on September 14, 2021, through January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine (90715) provided on October 8, 2021. 
 
You asked the Plan to pay for the TDAP vaccine (90715). You say that you contacted the doctor to have the 
claim corrected but have not succeeded. The Plan denied your request. The Plan says CPT code 90472 was 
overturned, and CPT code 90715 remains denied. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine 
(90715). The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine 
(90715). Therefore, we decided that the Plan does not have to pay for the TDAP vaccine (90715) provided on 
October 8, 2021.  
 
Benefits for the TDAP vaccine (90715) may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) provided on 
February 18, 2022. 
 
You asked the Plan to pay for ultrasound guidance. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93971 and 76937. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 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 76937 
is a column II code to column I code 93971. 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 ultrasound guidance for vascular access (76937) provided on 
February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 coagulation factor V analysis. 
 
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not a 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 gene (prothrombin coagulation factor II) and 
F5 gene (coagulation factor V) The F2 and F5 genetic tests are not considered to be clinically efficacious; 
therefore, testing is not medically necessary.  
 
We looked at the file and Medicare rules. Per LCD L35000, the requested F5 gene testing is not medically 
necessary, and therefore is not covered. Based on this information, we decided that Medicare rules for coverage 
of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 
coagulation factor V analysis.