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

 
We decided that the Plan does not have to pay for the lab services provided on January 26, 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 January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED) 
provided on May 13, 2022, to August 14, 2022. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator (AED). You say that you 
cannot afford the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator (AED). This item/service 
falls within the durable medical equipment (DME) and related supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the automatic external defibrillator (AED) provided on May 13, 
2022, to August 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (K0823) provided from March 1, 2022, 
through September 1, 2022. 
 
You asked the Plan to pay for the out-of-network services. You say that Medicare approved this previously and 
the Health Plan has already paid two months of rental towards it. The Plan denied your request. The Plan says 
the rendering provider is non-participating and there is not a referring provider. 
 
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 power wheelchair (K0823) provided from 
March 1, 2022, through September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 43605 and 49905) 
provided to the enrollee on March 24, 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 the records do not support the service 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 the denied codes is: 
 
CPT 43605: 
 
Biopsy of stomach, by laparotomy 
 
CPT 49905: 
 
Omental flap, intra-abdominal (List separately in addition to code for primary procedure)  
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 that a biopsy of stomach, by 
laparotomy is not supported as rendered by the operative report. Additionally, in terms of CPT 49905, the 
omental flap is reported in the operative record to support the duodenal bulb closure; however, it is not a 
primary or separate procedure and should be coded with a modifier to represent a secondary procedure as it not 
distinct from the suture repair of duodenal ulcer - CPT 43480. 
 
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 surgical services (procedure code 43605 and 49905) provided to the enrollee on March 24, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOneHeme comprehensive genomic profiling test (F1 
Heme) (CPT code 81455) provided on March 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is 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 pay for the laboratory service. Our physician 
reviewer found the requested service meets that requirement based on the details given. The review has 
determined that the medical records provided meet the requirements listed in the NCD for Medicare coverage. 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for FoundationOneHeme comprehensive genomic profiling test (F1 Heme) (CPT code 81455) provided 
on March 29, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies (K0553) provided on 
August 29, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that a decision was not 
made within the time frame. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We looked at the file, and Medicare rules. As the case file shows that the plan would have overturned these 
services if they had made the decision in time, the records support the services billed. The criteria for coverage 
of the requested CGM supplies are met. Based on this information, we decided that Medicare rules for 
coverage of the supplies have been met. Therefore, we decided that the Plan has to pay for the continuous 
glucose monitor (CGM) supplies (K0553) provided on August 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 
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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the reviewer found that the requested 
Intracept procedure is not 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab (Imfinzi). 
 
You asked the Plan to pre-approve Imfinzi. You say that you cannot have chemotherapy due to previous sepsis. 
The Plan denied your request. The Plan says the drug is not supported for your condition. 
 
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 Imfinzi. Our physician reviewer found 
that you have stage III non-small cell lung cancer. The requested use of Imfinzi is not FDA approved for your 
condition. Maintenance durvalumab is indicated for those that received chemotherapy with radiation. You have 
not received prior chemotherapy. The requested use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary in this case. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve durvalumab (Imfinzi).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow-up visit (99215) to be provided by an out-of-
network (OON) tertiary provider. 
 You asked the Plan to pre-approve an outpatient service. You say that you would like to go back to your 
previous provider. You say that you have a family history of cancer. You also say that they are monitoring your 
status. The Plan denied your request. The Plan says the service can be provided in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient service. Our reviewer says 
that the requested follow-up visit with a tertiary provider is not medically necessary. Our physician reviewer 
found the provided documentation does not support that you have a unique or difficult medical condition. The 
reviewer found that the Plan has adequate network providers that can provide treatment safely. Therefore, the 
reviewer found that the requested follow-up visit with a tertiary provider is not 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 an outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a follow-up visit (99215) to be provided by an out-of-network (OON) tertiary 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 31, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee must receive care from a network provider. 
 
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 an office visit provided on August 31, 2022, by an 
OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 70551. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says payment for code 70551 is bundled into payment for code 70546. 
 
  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 70551 
is a column II code to column I code 70546. 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 70551 billed for date of service June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genetic lab test provided on August 08, 2022. 
 
You asked the Plan to pay for a genetic lab test. You say that the provider should be filing the paperwork for 
this service, as this was medically necessary. 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 a genetic lab test 
provided on August 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on June 
29, 2022, through July 22, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered to for the 
prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675), provided on June 29, 2022, through July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81225, 81226, 81227, 
81230, 81231, 81232, 81240, 81241, 81291, 81306, 81306, 81328, 81355, 81335, 81401, 0031U, 0033U, 
81479, 81407, 81406 and 81238 provided March 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the CPT codes were denied as experimental, 
the medical records have been attached to this appeal. Please have a look at the attachment and reconsider the 
charges which were previously denied. The Plan denied your request. The Plan says the Plan does not have the 
information needed to consider this charge. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Genetic panels for inherited thrombosis risk as well as genetic response to 
medications is not a standard of care. There are only 5 genes recommended for determining inherited 
thrombosis risk and not clear that even these would be indicated for the enrollee. The service 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 81225, 81226, 81227, 81230, 81231, 81232, 81240, 
81241, 81291, 81306, 81306, 81328, 81355, 81335, 81401, 0031U, 0033U, 81479, 81407, 81406 and 81238 
provided March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on 
January 8, 2022, through January 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered to prevent deep 
vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675), provided on January 8, 2022, through January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390), purchased on June 3, 2022. 
 
You asked the Plan to pay for an oxygen concentrator. You say that the item was medically necessary. The 
Plan denied your request. The Plan says purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to 
pay for an oxygen concentrator (E1390), purchased on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81230, 81231, 
81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479) provided on 
May 25, 2022. 
 
 
 
 
 You asked the Plan to pay for laboratory services. You say that you disagree with the denial. You also say 
medical records have been attached to this appeal and you are requesting reconsideration of payment on this 
claim. The Plan denied your request. The Plan says they do not have the information needed to consider this 
charge. The Plan requested specific information to complete the review. The Plan needed all treatment records 
to support the necessity of the test performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The records show that the Plan requested treatment records which 
should have included laboratory results, name of laboratory, name and address of the referring provider, copies 
of an order from a rendering provider or a letter of medical necessity. The records also show documentation 
was never submitted. Based on this information, we decided that there is insufficient information in the record 
to determine if Medicare rules for coverage of laboratory services have been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81230, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479) provided on May 25, 2022.