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

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 24, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
show that 22 or more drug classes were tested on the date of service in question. 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 the drug testing services (G0483) provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter (99239) provided on November 7, 2022. 
 
You asked the Plan to pay for the 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. 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 the hospital inpatient or observation discharge 
day management; more than 30 minutes on the date of the encounter. 
 
Review of the file shows that this procedure was included in another claim under observation code 99238 on 
same date of service and it was processed on November 14, 2022. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital inpatient or observation discharge day management; more than 30 minutes on the 
date of the encounter (99239) provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on October 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99223) is included in the global 
surgery payment for the procedure (33264) provided on the same date of service. 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 the services (99223) provided on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the Healthy Heart Program benefits (99429). 
 
You asked the Plan to pre-approve the Healthy Heart Program benefits. You say that you missed several calls 
because you had a phone problem, and did not have the capacity to communicate with a care manager. You 
also say that you are requesting you not have this membership dropped because you are actively using it, and 
are very happy about it. The Plan denied your request. The Plan says that you do not meet the requirements of 
the Healthy Heart Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support the Plan's denial, and medical records were not 
provided for this case. This means that the Plan has not provided a valid reason for denying payment of the 
Healthy Heart Program benefits. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pre-approve the Healthy Heart Program benefits (99429).  
 
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 pay for the walker purchased on February 11, 2022. 
 
You asked the Plan to pay for the walker. You say that the item was medically necessary. The Plan denied your 
request. The Plan says you purchased this item through a vendor that is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker purchased on February 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostatic arterial embolization (37243). 
 
You asked the Plan to pre-approve a prostatic arterial embolization. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 a prostatic arterial embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record does not indicate the presence of an artery causing hemorrhage. There 
is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested 
service. 
 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 prostatic arterial embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a prostatic arterial embolization (37243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertical shock reduction feature for an approved 
prosthetic (L5988). 
 
You asked the Plan to pre-approve the vertical shock reduction feature. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of prosthesis. 
 
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 vertical shock reduction feature. 
Our reviewer says that this feature is not medically necessary. Our physician reviewer found there is no clinical 
documentation of the need for the additional feature. 
 
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 vertical shock reduction feature have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertical shock reduction feature for an approved prosthetic 
(L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service January 4, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that this item was medically necessary. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service January 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78452). 
 
You asked the Plan to pre-approve a SPECT scan. You say that you need this test, and it is medically necessary 
because there might be some cardiac issues that you are trying to find out about. The Plan denied your request. 
The Plan says the records do not show that you are unable to exercise, that you have an uninterpretable 
electrocardiogram (EKG), that you have a high pre-test probability, or that you have a history of a false 
positive exercise stress test. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
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 a SPECT scan have been met. Medical 
records were not provided for this case. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a single-photon 
emission computerized tomography (SPECT) scan (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a tertiary level retinal specialist. 
 
You asked the Plan to pre-approve an office visit with a tertiary level retinal specialist. You say that you go 
every six months to this provider to evaluate and closely monitor your eye health as it is a problem that could 
get worse. You say that this physician knows you and you do not want to change to another provider. The Plan 
denied your request. The Plan says your medical records do not show why you need a higher level of care and 
do not say that you cannot be treated with a standard level of care. Your condition can be managed at a lower 
level of care with a community provider. 
 
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 an office visit with a tertiary level 
retinal specialist. Our reviewer says that the requested office visit with a tertiary level retinal specialist is not considered medically reasonable and necessary in this case. Our physician reviewer found that per your last eye 
exam notes, you have a history of right eye macular hole and left eye normal with a low risk for macular 
hole. Both eyes are stable and there is no mention of future or anticipated intervention recommended. The 
community provider at a standard level of care, that has been approved by the Plan, is a retinal specialist as 
well. There is no medical reason or medical necessity for your eye care to be at a tertiary level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit with a tertiary level retinal specialist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an office visit with a tertiary level retinal 
specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has not been a four week trial of regular, daily, multiple-hour home usage of the 
E0650 or E0651. 
 
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 device. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee only tried the basic device once on January 11, 2023. The enrollee does not have unique 
characteristics that would indicate the segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 that the enrollee has knee osteoarthritis. 
She has not tried and failed the Plan's required drugs, Monovisc, Orthovisc, Synvisc, or Synvisc-One. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 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 Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service September 
14, 2022. 
 You asked the Plan to pay for procedure code 11721. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service September 14, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral upper blepharoplasty. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria 
are met. 
 
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 records do not show subjective 
complaints of significant interference or difficulty with vision or visual field. The visual field testing does not 
demonstrate a 12-to-15 degree superior field loss or 24 to 30 percent superior visual field impairment. The 
photographs show right eye margin to reflex distance 1 (MRD1) of about 3 millimeters and left eye MRD1 of 
about 2.5 millimeters. The criteria for coverage are not met and the bilateral blepharoplasty is not reasonable or 
medically necessary at his time. 
 
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 a bilateral upper blepharoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lntracept procedure. 
 
You asked the Plan to pre-approve a lntracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a lntracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI shows a disc herniation. The cause of back 
pain is unclear. 
 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 lntracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lntracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides beyond the 24 one-way rides to get 
routine (non-emergency) medical care. 
 You asked the Plan to pre-approve additional rides. You say that you thought you had unlimited rides, and 
were never told this benefit was limited to 24 rides. The Plan denied your request. The Plan says your request 
for rides in addition to the 24 one-way rides you are covered for exceeds the benefit limit. The Plan also says 
once those rides are exhausted, there are no additional rides available for the duration of the contract year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that as of April 25, 
2023, you had utilized 23 of the 24 one-way rides, and you had one more ride left under your supplemental 
transportation benefit. Further, the Plan says you had one ride scheduled for April 26, 2023, after which, you 
will have utilized the 24 one-way trips allowed. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional rides beyond the 24 one-way rides to get routine (non-emergency) medical care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (A9270) provided to you from November 28, 2022, 
to November 29, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 pay for the drugs (A9270) provided to 
you from November 28, 2022, to November 29, 2022.