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

 
We decided that the Plan has to pay for the diagnostic testing billed with codes G0453, 95937, 95864, 95939, 
95822, and 95925 provided on July 19, 2021. 
 
You asked the Plan to pay for the diagnostic testing billed with codes G0453, 95937, 95864, 95939, 95822, and 
95925. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that this 
procedure is included in the primary procedure. 
 
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. Review of the file shows that the Plan has denied these services due to these 
procedures included in the primary procedure. The case file does not provide documentation to show what 
procedure these codes are included in. In addition, no Medicare rules were provided to support this denial. The 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the diagnostic testing 
billed with codes G0453, 95937, 95864, 95939, 95822, and 95925 provided on July 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have severe chronic obstructive pulmonary disease (COPD) and repeated recent 
hospitalizations for exacerbations. If you do have chronic carbon dioxide (CO2) retention, may benefit from 
bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during 
sleep. There is no evidence that this treatment has been tried and failed as an outpatient. Medicare does not cover a home ventilator at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on May 01, 2022, to 
May 26, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on May 01, 2022, to May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has obstructive sleep apnea (OSA) and pulmonary fibrosis. The medical records are of 
poor visual quality. However, there is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic 
restrictive disease, or neuromuscular disease. The enrollee does not have a diagnosis for which Medicare 
covers a home ventilator. Medicare does not cover a home ventilator when used at settings that can be provided by bilevel positive airway pressure (BiPAP). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 20, 2022. 
 
You asked the Plan to pay for the testing services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says the testing did not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 The file shows that a Tempus liquid biopsy panel test was provided. The records in the case file do not show 
that the testing at issue is FDA approved. Based on this information, we decided that Medicare rules for 
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for 
the gene panel testing provided on August 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832), provided on June 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that the service should be covered. The Plan denied 
your request. The Plan says this provider is out-of-network. 
 
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 psychotherapy (90832), provided on June 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carbidopa-Levodopa. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is self-administration. 
 
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. Therefore, we decided that the Plan does not have to pre-approve Carbidopa-Levodopa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation provided to the enrollee on July 28, 2022. 
 
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) 33340 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 33340 is "Percutaneous transcatheter closure of the left 
atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), 
left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation." 
 
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 the records support that co-surgeons 
performed this procedure. Therefore, modifier 62 should have been appended to CPT 33340. 
 
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 percutaneous transcatheter closure of the left atrial appendage with endocardial implant, 
including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage 
angiography, when performed, and radiological supervision and interpretation provided to the enrollee on July 
28, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the colonoscopy, flexible (45390), and colonoscopy with removal of 
tumors (45385) provided on September 16, 2022. 
 
You asked the Plan to pay for the diagnostic services. You say that your primary care physician referred you to 
this provider for the services. You say that The Plan denied your request. The Plan says that out-of-network 
services are not covered. 
 
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. Specifically, the file does not substantiate the Plan's denial. The Plan did not 
include a copy of the original claim. Without this information, we cannot determine who the referring provider 
was. Therefore, we decided that the Plan has to pay for the colonoscopy, flexible (45390), and colonoscopy 
with removal of tumors (45385) provided on September 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (86849) provided on March 17, 2022. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this service was needed for re-entry after 
travel. The Plan denied your request. The Plan says this service was obtained out of the plan area from a non-
network provider and was not urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.    
We looked at the file and Medicare rules. This test was solely for travel purposes. No clinical records were 
provided to show that this service was emergent or urgent. Based on this information, we decided that 
Medicare rules for coverage of the COVID-19 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for COVID-19 testing (86849) provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the zoster vaccine (90750) and administration (90471). 
 
You asked the Plan to pay for the zoster vaccine and administration. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the zoster vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the zoster vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for the zoster vaccine (90750) and 
administration (90471).  
 
Benefits for the zoster vaccine and administration 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services and an injection (99213 & J7321) 
provided on May 12, 2022. 
 
You asked the Plan to pay for the physician services and injection. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 find that CPT codes 99213 & J7321 are not supported in the medical record. Specifically, code 99213 is 
included in the global surgery package of code 20610 that was also billed. Code J7321 is defined as 
Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose. Records show 
Orthovisc was injected. There is a more appropriate code for this injection (J7324). Based on this information, 
we decided that Medicare rules for coverage of the physician services and injection have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services and an injection (99213 & 
J7321) provided on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Continuous positive airway pressure (CPAP) device 
(E0601), provided on September 9, 2022, through October 8, 2022. 
 
You asked the Plan to pay for a CPAP device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says there is no evidence you adhered to the required CPAP therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a CPAP device requires 
adherence to therapy as defined as use of a PAP greater then or equal to 4 hours per night on 70% of night 
during a consecutive thirty day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, there is no evidence you adhered to the required 
CPAP therapy. Therefore, we decided that the Plan does not have to pay for a Continuous positive airway 
pressure (CPAP) device (E0601), provided on September 9, 2022, through October 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an astigmatism correcting intraocular lenses (A-C IOL) 
(V2787) provided on April 5, 2022 to April 19, 2022. 
 
You asked the Plan to pay for the astigmatism correcting intraocular lenses. You say that this service should be 
covered. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism 
correcting intraocular lenses (A-C IOL) (V2787) provided on April 5, 2022 to April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
panoramic radiographic image (D0330) provided on October 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you told the dentist you had no money and only 
wanted the services the Plan would pay for. You also say that the dentist confirmed with the Plan the services 
would be covered. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
June 23, 2022, and the panoramic radiographic image  (D0330) was exhausted on date of service October 3, 
2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140), and panoramic radiographic image (D0330) provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 16, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab services provided on July 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you prefer to admit to acute rehab because you were 
independent before her hospitalization and want to return to being independent. The Plan denied your request. 
The Plan says your records do not show that your rehab needs are complex, medically necessary care may be 
provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found while you may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that you require this therapy on an intensive IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's 
medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is reported to be medically stable for discharge to a skilled nursing 
facility placement.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.