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

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 5, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says the 
claim was untimely and the submission did not meet the exception criteria guidelines outlined in the Medicare 
Claims Processing Manual. 
 
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 diagnostic radiology services was not filed until February 15, 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 diagnostic radiology services provided on 
February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 22, 
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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 15777 is not supported in the medical record. Specifically, this code has a bilateral surgery indicator of "1" which means that the units of service per day cannot exceed 1. 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 provided to the enrollee on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot (procedure code L4360) received on March 
16, 2022. 
 
You asked the Plan to pay for the boot. You say that you didn't request this, but your doctor thought it was 
necessary. The Plan denied your request. The Plan says this service was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that equipment code L4360 is not supported in the medical record. Specifically, the correct modifier 
was not used for this code. This code requires either modifier KX, GA, or GZ. The claim only had a modifier 
for LT - left side. Based on this information, we decided that Medicare rules for coverage of the boot have not 
been met. Therefore, we decided that the Plan does not have to pay for a walking boot (procedure code L4360) 
received on March 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan has no contractual obligation to cover additional physical 
therapy services that are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not reasonable or necessary. Our physician reviewer found that it 
is unclear per the documentation if continued therapy is required to prevent regression of the enrollee's 
lymphedema, and if the enrollee requires the ongoing services of a skilled therapist to accomplish this. The left 
upper extremity measurements have been stable at approximately 203 cm, and she is using her compression 
garments consistently. Therefore, the additional therapy cannot be considered 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
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 Bi-level positive airway pressure (Bi-PAP) 
was tried in the hospital and failed. You say that with the diagnosis of chronic respiratory failure and chronic 
obstructive pulmonary disease (COPD) a BiPAP does not have the capability of delivering a set volume of air 
and provide a back-up respiratory rate. You say that a non-invasive ventilator has the function to deliver on 
every breath a tidal volume of 600cc. Without the non-invasive ventilator the enrollee is at high-risk of 
frequent readmission due to elevated carbon dioxide poisoning. You say that during the enrollee's admission 
she would breathe along with backup rate and that the non-invasive ventilator helped her adequately sleep and 
take the breaths needed to prevent carbon dioxide retention. The Plan denied your request. The Plan says use of 
a portable ventilator to deliver ventilatory support via settings that could be equally provided by a Bi-PAP with 
average volume assured pressure support (AVAPS) settings is inconsistent with Medicare coverage rules. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient was recently admitted with acute on chronic hypercarbic respiratory failure, 
likely due to obesity-hypoventilation syndrome, with COPD and narcotics contributing to the hypoventilation.  
This patient may benefit from BiPAP with AVAPS during sleep.  But Medicare does not cover a home 
ventilator when used as BiPAP.  The records show no evidence of BiPAP failure as an outpatient. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMdx test provided to the enrollee on April 5, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test is experimental, investigational, 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.  
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that routine use of this test at this time is not recommended for prostate cancer. SelectMdx is considered 
to be investigational for this use at the present time. There is no direct evidence that supports the clinical utility 
of the test, and the chain of evidence is incomplete due to the limitations in clinical validity and clinical utility. 
The evidence is insufficient to determine the effects of the technology on health outcomes. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the SelectMdx test provided to the enrollee on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 16, 
2022. 
 
You asked the Plan to pay for the services. You say that the medical records support payment The Plan denied 
your request. The Plan says the provider appears to be billing separately for the components that were done on 
a single specimen. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
laboratory report describes a clean catch urine sample collected for infectious agent detection. In this case, the 
denied procedure codes - 87653-59, 87481-59, 87641-59, 87640-59, and 87798-59 - would be incidental to 
CPT 87801, as this procedure is the more comprehensive procedure, and would include these components. 
Modifier -59 would not be supported 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 not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 25, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that you have a serious problem with your right eye 
and you were diagnosed to have laser surgery to remove the cloudiness on your lens. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2022 billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321 and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this letter documents the medical 
necessity of the test requested for the enrollee to assist in the treatment, prognosis and diagnosis of their cancer. 
The Plan denied your request. The Plan says the documentation does not support that the services rendered 
were medically necessary. 
 
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 
January 19, 2022 billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317, 81321 and 81194.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee has severe COPD and needs 
treatment with a NIV and that a NIV is medically necessary for the enrollee as prescribed. The Plan denied 
your request. The Plan says the enrollee does not meet the necessary medical requirements. 
 
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 the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has severe COPD and was recently admitted with an accidental narcotic overdose and COPD exacerbation. Arterial blood gases was consistent with acute on chronic hypercarbic respiratory 
failure. The enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support during sleep as an outpatient. But Medicare does not cover a home ventilator when used as 
BiPAP. A home ventilator 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ureterolysis provided to the enrollee on October 27, 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 do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 50715 is "Ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis." 
 
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 operative report does not 
describe ureterolysis as a separate distinct service from the primary procedure. The report describes an anterior 
interbody technique for a lumbar arthrodesis. The modifier is not supported in the operative report. 
 
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 ureterolysis provided to the enrollee on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-positional patient transfer system represented by 
code E1035. 
 
You asked the Plan to pre-approve code E1035. You say that the records provided support the need for the 
requested device. The Plan denied your request. The Plan says the request does not meet the Medicare or health 
plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that multi-positional patient transfer systems are covered 
when the beneficiary requires supine positioning for transfers.  
 
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 code E1035. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found you do not require a supine position to transfer. You will require a walker or wheelchair. Those devices are excluded if you have a multi-positional 
lift. The requested lift does not meet your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code E1035 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a multi-positional patient transfer system represented by code E1035.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 16, 2022. 
 
You asked the Plan to pay for physician's services. You say that you do not understand why you need a referral 
for a routine eye doctor appointment that you have every year. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the 
services 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 physician's services provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal decompression chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the Medicare criteria for durable medical equipment as it is not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the chair. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that per Medicare guidelines, there is insufficient evidence supporting medical necessity of decompression via 
cervical and pelvic traction. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a spinal decompression chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says any additional requests for a home health aide will require a clinical update on function 
and goals. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that the rate of your 
improvement over a ten-day period, and the level of function on 8/26, indicate that additional therapy is not 
medically reasonable or necessary. There is no evidence that you need more visits than those already approved. 
You are functioning at an outpatient level and are no longer homebound. You are able to improve with a 
repetitive exercise program. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
genetic testing. We found no exception that would require the Plan to pay for the genetic testing. The records 
provided for review do not show that the genetic testing was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 25, 2022, by 
an out-of-network (OON) provider.