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

 
We decided that the Plan has  3D rendering provided to the enrollee on September 21, 2021. 
 
You asked the Plan  the services. You say that the denied code is supported in the records. The Plan denied 
your request. The Plan says that non-participating providers are required to furnish necessary information to the 
health plan when requested. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request  the services. Our reviewer says that the requested 
services are considered medically reasonable and necessary in this case. Our physician reviewer found that the 
use of 3D rendering in this case was necessary in order to ensure targeted biopsy when the magnetic resonance 
imaging (MRI) was fused with the ultrasound. The technique and reasoning for same were explained in the 
report, and as such confirms to the applicable guidelines for this request. 
 
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 services have been met. Therefore, we decided that the Plan has  3D 
rendering provided to the enrollee on September 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional payment for computed tomography (CT) of 
abdomen and pelvis (74177) and angiography of the chest (71275) provided to the enrollee on June 6, 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 the records submitted do not indicate that these separate services were performed or 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 the denied codes is: 
 
CPT 71275: 
 
Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast 
images, if performed, and image postprocessing 
 
CPT 74177: 
 
Computed tomography, abdomen and pelvis; with contrast material(s) 
 
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 the enrollee had one computed 
tomography angiography (CTA) of the chest and one computed tomography (CT) of the abdomen and pelvis 
on 6/6/21, signed by the doctor. There are two copies of these reports in the records, but they are duplicates. 
 
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 additional payment for computed tomography (CT) of abdomen and pelvis (74177) and 
angiography of the chest (71275) provided to the enrollee on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (AED) rendered on 
February 20, 2021. 
 
You asked the Plan to pay for these services. You say that you were having issues with your software. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until April 12, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the automatic external defibrillator (AED) rendered on February 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 5, 2020 billed with 
codes 81405, 81479, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the dneial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 5, 2020 billed with codes 81405, 81479, and 81406.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for radiation therapy services provided from August 2, 
2021, through August 31, 2021. 
 
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you were informed to 
pay $2,393.84 and you would be reimbursed $1,518.42. You say that there is nothing that says this should not 
be covered and you need the money back. The Plan denied your request. The Plan says that the coinsurance 
applied correctly. 
 
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 2021 Evidence of Coverage was requested but not submitted. This means 
that we cannot determine the cost you are being asked to pay is correct or justified by the contract. 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 waive the coinsurance 
for radiation therapy services provided from August 2, 2021, through August 31, 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 pay for the general health panel rendered on January 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
rendered on January 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Quetiapine. 
 
You asked the Plan to pre-approve Quetiapine. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Quetiapine.  
 
Benefits for Quetiapine 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: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on October 31, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that in addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has stage IV tonsil cancer. The review has determined that 
testing for the FANCC gene was reasonable 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve laboratory services provided to the enrollee on October 31, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on August 17, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81599) provided on August 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were referred by the enrollee's 
physician. The Plan denied your request. The Plan says the provider and referring physician are 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 lab services (81599) provided on August 20, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power operated vehicle, group 1 standard, patient weight 
capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you have intense swelling of the legs 
causing them to weep, which in turn has only increased the issues with mobility. You also say you need 
assistance to move about within your home and you are home bound due to mobility issues. You are in 
desperate need to have the power scooter to afford some freedom that has been taken away due to health issues. 
The Plan denied your request. The Plan says that the request is not medically necessary. The Plan also says you 
must have an order from your provider. Your records do not show that you have had an evaluation by someone 
who is an expert on scooters and can certify you can operate safely the type you requested. 
 
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. It is the plan's responsibility to obtain those records as they requested them from 
a network provider/agent of the plan. Therefore, we decided that the Plan has to pre-approve a power operated 
vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 x-ray provided on January 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Androderm. 
 
You asked the Plan to pre-approve Androderm. You say that the enrollee has been on this medication since 
2014. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug plan. 
 
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 Androderm.  
 
Benefits for Androderm 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a neck injection provided on October 22, 
2021. 
 
You asked the Plan to waive the copayment for a neck injection. You say that you should only have to pay an 
MRI copayment. The Plan denied your request. The Plan says the copayment applied was 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 $275 
copayment for in network outpatient surgery.  
 
You have been asked to pay a $275 copayment for a neck injection. A neck injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a neck injection provided on October 22, 2021.  
 Your complaint about the facility being an hour away is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) radiologic examination, 
gastrointestinal tract (74230) radiologic examination, spine, cervical (72040) radiologic examination, mandible 
(70100) radiologic examination, teeth (70310) radiologic examination, chest (71045) radiologic examination, 
gastrointestinal tract, upper (74240) provided March 2, 2022.   
 
You asked the Plan to pay for the portable x-ray services. You say that after reviewing prior medical records, 
additional information has been added. Please reconsider. The Plan denied your request. The Plan says the 
services are not covered under the plan benefits and is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that items and services that 
are not medically necessary are not covered. 
 
In this case, we find that CPT codes are not supported in the medical record. Specifically, the services were 
performed at a nursing home (via mobile van/portable x-ray) which is an excluded place of service. The 
provider is also billing the technical component modifier and the professional component modifier on the same 
claim. Both the modifier 26 and modifier TC CPT codes cannot be paid when billed by the same provider with 
the same Tax ID number. Based on this information, we decided that Medicare rules for coverage of the 
portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99204) radiologic examination, gastrointestinal tract (74230) radiologic examination, 
spine, cervical (72040) radiologic examination, mandible (70100) radiologic examination, teeth (70310) 
radiologic examination, chest (71045) radiologic examination, gastrointestinal tract, upper (74240) provided 
March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 5, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says you were seen 
for a medical diagnosis of cataracts, right eye. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99283) 
provided to the enrollee on February 16, 2022, and February 17, 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 medical records meet the criteria for CPT 99283, as normally a lower level emergency 
department code would be reported for a non-emergency condition. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity." 
 
 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 the review indicates that the 
enrollee was evaluated in the emergency department after a ground level fall. The evaluation revealed no 
evidence for fracture or active cardiac or neurological issues. The review has determined that the medical 
records met the criteria for CPT 99283, as normally a lower-level emergency department code would be 
reported for a non-emergency condition. 
 
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 emergency department services (procedure code 99283) provided to the enrollee on February 
16, 2022, and February 17, 2022.