Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on 
November 19, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
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 orthosis. Our physician reviewer found 
there is no specific clinical rationale for the requested durable medical equipment (DME). The review has 
determined that the requested DME is not supported by the records provided. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel testing (CPT code 81479) provided 
on October 21, 2021.  
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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. 
 
The member had Tempus Gene Panel testing billed with multiple CPT codes, including 81479 with a -59 
modifier. This one code was submitted on its own on a separate claim form; the other codes were submitted on 
a different claim form, but testing was performed at the same time on the same specimen. The denial remains 
upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. Additionally, modifiers should not be 
used to report multiple codes when a single specimen is tested. This testing was done on a single blood/tissue 
specimen. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel testing (CPT 
code 81479) provided on October 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the 
abdomen rendered on December 25, 2021. 
 
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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the computed tomography angiography (CTA) of the abdomen rendered on December 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), platelet rich plasma, any site, including 
image guidance, harvesting and preparation when performed (CPT code 0232T). 
 
You asked the Plan to pre-approve the injection. You say that the platelet/stem cell treatments have worked on 
hundreds of thousands of people worldwide. The Plan denied your request. The Plan says there is insufficient 
high-quality evidence to justify the use of PRP for the treatment of any condition except for within the confines 
of a well-designed clinical trial. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the injection have not been met. The rules say that this is a NON-
coverage policy for all platelet rich plasma injections and/or applications as a means of managing 
musculoskeletal injuries and/or joint conditions. You sent additional information. Therefore, this service is not 
covered by Medicare or your health plan. Therefore, we decided that the Plan does not have to pre-approve 
injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when 
performed (CPT code 0232T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty, knee, condyle and plateau (27447) provided 
September 14, 2021. 
 
You asked the Plan to pay for the outpatient surgery. You say that the refund request is in error. There is no 
over payment for services rendered. The Plan denied your request. The Plan says this is a correction of a 
previously paid claim. 
 
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 find that CPT code 27447 is not supported in the medical record. Specifically, the records show 
that duplicate payments were made for CPT code 27447 and the provider was paid twice for the same service. 
The first payment was paid on check dated 09/22/2021 and the second payment paid on 09/30/2021. Based on 
this information, we decided that Medicare rules for coverage of the outpatient surgery have not been met. 
Therefore, we decided that the Plan does not have to pay for the arthroplasty, knee, condyle and plateau 
(27447) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 7, 2021 by a non-
participating provider. 
 
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 were rendered by a non-participating provider without prior authorization. 
 
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 office visit provided on July 7, 2021 by a non-
participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing coded as 87798, 87481, 87801 
and 87150 provided May 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the reports and records to 
prove that services are rendered due to medical necessity. You request reconsideration and reprocessing of your 
claim towards payment. The Plan denied your request. The Plan says PCR testing is considered unproven and 
not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at 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 Urine PCR panel testing coded as 87798, 87481, 87801 and 87150 provided May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of a modality to 1 or more areas; hot or cold 
packs (CPT code 97010) and supplies and materials (CPT code 99070) provided on June 16, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are 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.  
Procedure code(s): 97010 and 99070, which has a status indicator of 'B' on the CMS Physician Relative Value 
File, is always bundled into payment for other services not specified and no separate payment is made per 
Medicare. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or more 
areas; hot or cold packs (CPT code 97010) and supplies and materials (CPT code 99070) provided on June 16, 
2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the shoe supplies (CPT code(s): A5512 and A5500) provided on 
November 22, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the diagnosis code(s) associated to them are mismatched to the procedure modifier 
on the claim line. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The rules say that unspecified 
side is used when the record does not specify which side the condition occurs on. The Plan has not supported 
that the use of the unspecified side code is incorrect. 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 pay for the shoe supplies 
(CPT code(s): A5512 and A5500) provided on November 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on November 3, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 office services provided on November 3, 2021, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nodify CDT lung testing (CPT code 81599) provided on 
October 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the requested service does not meet the Industry Standard Guideline for 
management of a solitary pulmonary nodule. 
 
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 based on current National Comprehensive Cancer Network (NCCN) guidelines, 
management of an 8 mm isolated solid lung nodule includes a follow-up low dose CT scan (LDCT) in 6 months. If unchanged, continue annual LDCT unless a new change in size changes in clinical history of 
imaging. If unchanged, continue annual LDCT. If there is a high suspicion of lung cancer based on clinical 
history or imaging, then nodule biopsy or surgical excision are the recommended testing options. The review 
has determined that the items/services at issue in this case are not medically reasonable or 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 Nodify CDT lung testing (CPT code 81599) provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided on September 2, 
2021. 
 
You asked the Plan to pay for the chest x-ray. 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, we have confirmed that code 
71045-26 is a column II code to column I code 36573. 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 the chest x-ray (CPT code 71045) provided on 
September 2, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing services provided on October 14, 2021. 
 
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim 
reprocessed and approved for payment as the claim is not a duplicate. The Plan denied your request. The Plan 
says that payment has been previously made for these services. 
 
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. In this case, the Plan has denied payment claiming that payment for these 
services was already rendered and that the corresponding claim is a duplicate. There is no evidence provided in 
the case file such as an explanation of benefits or claim form that payment has already been made for these 
services. Therefore, we decided that the Plan has to pay for the laboratory testing services provided on October 
14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says an 
epidural steroid injection does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale* for at least three months.
  
 
 
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 epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically reasonable or necessary. Our physician reviewer 
found the enrollee did not achieve 50% pain relief for a 3-month period. Therefore, the request is deemed not 
medically reasonable or 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for therapeutic interventional radiological 
procedures involving the arterial system; intracranial, intracardiac, or aortic (CPT code 01926) provided on 
March 23, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are 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. 
 
Payment is not allowed for this service because it is missing the required anesthesia modifier. Therefore, we 
decided that the Plan does not have to pay for anesthesia for therapeutic interventional radiological procedures 
involving the arterial system; intracranial, intracardiac, or aortic (CPT code 01926) provided on March 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM reader. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine you received on February 8, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you are in a weakened condition due to brain 
surgery and stroke, and your doctor felt this shot was necessary. The Plan denied your request. The Plan says 
this vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine you received on 
February 8, 2022.  
 
Benefits for the Shingles vaccine 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: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services were not pre-authorized and there are no records showing this 
service was emergent. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Maxima 3 #SC901 Power Scooter, motorized 
outdoor scooter with lift for a car (E1399). 
 
You asked the Plan to pre-approve a motorized outdoor scooter. You say that the power chair is necessary due 
to very limited mobility, and you have fallen several times with the walker. The Plan denied your request. The 
Plan says Medicare will only cover durable medical equipment for use in the home. The Plan also says your 
records do not show that you have been assessed for use of a wheelchair or had a home assessment to 
determine if the requested device will fit in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Pride Maxima 3 #SC901 Power Scooter, motorized outdoor scooter with lift for a car 
(E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the boat docking fee paid for September 13, 2021. 
 
You asked the Plan to pay for the boat docking fee. You say that sailing is a physical activity, and you feel it 
should be covered. The Plan denied your request. The Plan says this service is not covered under your wellness 
benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to $200 
reimbursement each year for qualified health-related wellness activities or services. 
 
Though the Plan offers a wellness benefit beyond Medicare coverage, the boat docking fee is not among those 
covered items in this benefit. Therefore, we decided that the Plan does not have to pay for the boat docking fee 
paid for September 13, 2021.