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

 
We decided that the Plan has to pay for the genetic testing services provided on May 22, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved based on the medical records. The Plan denied your request. The Plan says that this claim has 
been billed with an inconsistent date of service. 
 
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 case file does not show that the lab service does not meet any of the exceptions outlined in the Medicare 
ruling. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request. Therefore, we decided that the Plan has to pay for the genetic testing 
services provided on May 22, 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 pay for the nail debridement (11720) provided on May 20, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement service. You say that the enrollee informed the office that they 
were covered under Medicare. You say that due to the enrollee misleading the office of incorrect insurance, the 
office was unable to obtain authorization. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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 in this case is not a network provider with the Plan. 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 nail debridement (11720) provided on May 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-area office visit (99204) provided on November 
29, 2021. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was experiencing pain. You say that 
vascular evaluation was medically necessary. You also say that this claim should be reconsidered. The Plan 
denied your request. The Plan says the service in this case was not urgent or emergent in nature. 
 
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 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 office visit. Our reviewer says that the 
out-of-area office visit is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee could have foreseen requiring the services prior to leaving their service area. The 
reviewer found provided records do not document that the clinical circumstances of the visit were an 
emergency and urgently needed services. The reviewer found the enrollee had been previously evaluated and 
treated for the left thigh pain and that it had been ongoing for seven months prior to this visit, nothing in the 
provided records suggests that a reasonable delay to see an in-network provider for a second opinion would 
have placed the enrollee at a risk that would have been a serious jeopardy to her health. Therefore, the reviewer 
found the out-of-area office visit was 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 the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the out-of-area office visit (99204) provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that this is a non-invasive, highly recommended 
treatment modality due to the location of the enrollee's lesions, as well as their comorbidities and current 
medications. You say that the requested treatment should be started as soon as possible to reduce further 
complications. The Plan denied your request. The Plan says the requested service is not covered by Medicare or 
the health plan. 
 
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 US-IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found ultrasound guided radiation therapy (US-IGRT) is not considered a standard of care for the treatment of 
squamous cell skin cancer. Use is not supported by the National Comprehensive Cancer Network (NCCN) 
Guidelines or the medical literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code A0425. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 342 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis and the foot heel stabilizer provided 
on May 17, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis and the foot heel stabilizer. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation submitted did not sufficiently support need for the 
billed codes. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and the 
foot heel stabilizer provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home 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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the code at issue is not incidental to the 
primary procedure. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) billed for date of service 
November 19, 2021. 
 
You asked the Plan to pay for moderate sedation services. You say that you have provided records to support 
the code at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is 
not paid in the facility setting. You can find this information in the Physicians Fee Schedule Final Rule. 
 
 
  We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for moderate sedation services (99153) billed for date of service November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on June 15, 2022. 
 
You asked the Plan to pay for the vision services. You say that this provider has been your provider for some 
time and has been in-network. You say that on this recent visit you were not notified that the provider is not in-network. The Plan denied your request. The Plan says you must receive vision services from an in-network 
provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained from a provider in the Plans vision vendor network. 
 
We looked at the file and the Plan's rules. The file shows that the vision services were not obtained from a 
provider in the Plans vision vendor network. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
vision services provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 11, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the testing meets the criteria for coverage. The 
Plan denied your request. The Plan says the claims have an unacceptable diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that the laboratory shall report only one unit of CPT code 
81479 for Guardant 360 testing. 
 
We looked at the file and Medicare rules. This was a Guardant 360 test that was not billed with a single unit of 
CPT code 81479, as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient hospital admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 this service. Our reviewer says that an 
acute inpatient hospital admission is not medically necessary.  Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on October 17, 
2022 with a fifteen minute episode of unresponsiveness; which self-resolved. The enrollee complained of  
left-sided chest pain. The enrollee had not taken any of his medications for the previous two days. In the ED his 
issues resolved; he was evaluated with a history and physical exam, laboratory studies, chest x-ray, and 
electrocardiogram. There were no abnormalities noted and he was admitted to telemetry. The enrollee 
underwent magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the 
head and neck, and transthoracic echocardiography for a cardiovascular work-up.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth, completely bony 
(D7240). 
 
You asked the Plan to pre-approve removal of an impacted tooth. You say that you do not agree with the denial 
and are requesting reconsideration. The Plan denied your request. The Plan says the service is not covered 
under your benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of an impacted tooth, completely bony (D7240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code 99222. 
 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 99214 
is a column II code to column I code 99222. 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 99214 billed for date of service May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) with 
the requested power options/features. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for a Group 3 power wheelchair (PWC) with 
the requested power options/features. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found there is no documentation that the group 3 power wheelchair with multiple power option and other 
accessories at issue in this case meets all Medicare criteria for medically reasonable and necessary for you. 
Provided records document that your quadriparesis and mobility impairment are due to your arthritis and 
rheumatic condition and not due to a neurological condition, myopathy, or congenital skeletal deformity as 
required by the LCD: Power Mobility Devices (L33789) for coverage of a group 3 power wheelchair. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (CPT code K0861) with the requested power options/features.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (81455) provided on August 25, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that coverage criteria has not been met. 
 
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 genetic testing. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found due to pancytopenia this patient was suspected of having myelodysplastic syndrome. Per the 
National Comprehensive Cancer Network Guidelines Genetic testing for somatic mutations (i.e., acquired 
mutations) in genes associated with myelodysplastic syndromes (MDS) is highly recommended. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve genetic testing (81455) provided on August 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Hempvana Maximum Strength Pain Relief Cream 
provided on July 16, 2022. 
 
You asked the Plan to reimburse you for Hempvana Maximum Strength Pain Relief Cream. You say that pain 
relief cream is a covered item for the Pick Your Perks program. The Plan denied your request. The Plan says 
based on the members benefit plan and the Pick Your Perks program, Hemp oil related products are not 
eligible. Hemp oil is also considered an alternative medicine which are not covered under the Pick Your Perks 
program. 
 
The Plan contract covers a supplemental Pick Your Perks program. The Plan says that the benefit covers OTC 
items that must be included on the Plans allowed items list. Ineligible items include, but are not limited to, the 
following: Alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. 
 We looked at the file and Medicare rules. The file shows that the cream you purchased is not a Pick Your Perks 
OTC eligible item. Therefore, we decided that the Plan does not have to reimburse you for Hempvana 
Maximum Strength Pain Relief Cream provided on July 16, 2022.