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

 
We decided that the Plan does not have to pay for the diagnostic procedures (75726, 75774, and 76380) and 
moderate sedation services (99152 and 99153) provided on November 4, 2021. 
 
You asked the Plan to pay for codes 75726, 75774, 76380, 99152, and 99153. You say that you would like the 
Plan to reconsider their denial of payment. 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. 
 
In this case, the CPT Code Manual definition of code 75726 is Angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation. The definition of 
code 75774 is Angiography, selective, each additional vessel studied after basic examination, radiological 
supervision and interpretation (List separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 75726 and 75774. Our reviewer says that the medical 
records do not support the use of modifier 59 with the billing of codes 75726 and 75774 provided on January 7, 
2022. Our reviewer found the billed code of 37243 states that all vascular road mapping procedures and 
delivery of the yy 90 is inclusive of all angiographic procedures during this examination/procedure.  Thus, 
CMS does not permit the separate billing for each catheter placement into different arteries under the code used 
in this case, 37243.  That code specifies that all road mapping and other tests at the same siting are not to be 
billed separately.  Rather they are included as part of the billed code 37243. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 75726 and 75774 have not been met.  
 
We have also confirmed that code 76380 is a column II code to column I code 37243. This claim has not been 
billed with an appropriate modifier to bypass the edit.  
 
We have also confirmed that codes 99152 and 99153 are column II codes to column I code 77290 with a 
modifier indicator of 0. The column II codes are therefore not payable. 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 diagnostic procedures (75726, 75774, and 
76380) and moderate sedation services (99152 and 99153) provided on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab. 
 
You asked the Plan to pre-approve durvalumab. You say that the information submitted supports the need for 
the requested drug. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve durvalumab. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found durvalumab is not the immunotherapy of 
choice for metastatic disease. The use of durvalumab in the enrollee's clinical scenario is not supported by one 
of the major drug compendia or by clinical research. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) additional teeth to be added to an existing 
partial denture (D5650). 
 
You asked the Plan to pre-approve 2 additional teeth to be added to an existing partial denture. You say that 
you need this partial done so that you can eat on a daily basis. Without the partial, you only have 5 teeth on the 
bottom. The Plan denied your request. The Plan says the benefit for adding teeth to a partial is one every 36 
months. You have exceeded your benefit for this service. 
 
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. The Plan covers one additional 
tooth to an existing partial denture every 36 months.  
 
 
 
 
 
 We looked at the file and Medicare rules. The records show you received an additional tooth to your existing 
partial denture on October 19, 2021; therefore, you have exceeded your benefit for this service. Therefore, we 
decided that the Plan does not have to pre-approve two (2) additional teeth to be added to an existing partial 
denture (D5650).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of an oral bisphosphonate and Zoledronic acid before they will approve the requested drug, 
Prolia. Based on the medical records provided, the enrollee has tried and failed two oral bisphosphonates but 
there is no indication that the enrollee has tried and failed Zoledronic acid. Based on the medical records 
provided and the Medicare-approved major drug compendia, there is no indication that Zoledronic acid would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by the requested out-of-network 
provider. 
 
You asked the Plan to pre-approve dialysis to be provided by the requested out-of-network provider. You say 
that you do not want to change to the contracted dialysis facility. The Plan denied your request. The Plan says 
that the Plan has a contracted facility available to offer the same services requested, at the same distance, the 
same time shift and with your current nephrologist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis to 
be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on November 25, 
2021. 
 
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on November 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are medically necessary and should 
be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve Contour Next test strips. You say that you are requesting reconsideration for 
the denied test strips. The Plan denied your request. The Plan says diabetic supplies are limited to specific 
preferred brands. Exceptions are only made if there is a medical justification why the specific preferred brands 
cannot be used. 
 
 
 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. Based on this information, we decided that Medicare rules for 
coverage of Contour Next test strips have not been met. Specifically, the documentation submitted does not 
include any clinical information to verify that the enrollee has tried and failed the Plan's preferred brands or 
that the Plan's preferred brands would be contraindicated for the enrollee. Therefore, we decided that the Plan 
does not have to pre-approve Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychiatric services provided on December 28, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 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 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 Psychiatric services provided on December 28, 
2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete bilateral noninvasive physiologic studies of 
upper or lower extremity arteries (93923) provided on January 7, 2022. 
 
You asked the Plan to pay for code 93923. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the complete bilateral noninvasive 
physiologic studies of upper or lower extremity arteries (93923) provided on January 7, 2022, have been met. 
The medical records provided are insufficient to determine if Medicare criteria have been met. Therefore, we 
decided that the Plan does not have to pay for the complete bilateral noninvasive physiologic studies of upper 
or lower extremity arteries (93923) provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 13, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not there at the time they say. You would 
like the plan to go over your claim, which you received, and credit your account. The Plan denied your request. 
The Plan says after speaking with the servicing physician, the member has indeed been seen and there are 
medical notes that indicate as such. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 13, 2022 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on September 16, 
2021 to December 27, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services can be received in-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 outpatient mental health services provided on 
September 16, 2021 to December 27, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nurtec ODT tablet. 
 
You asked the Plan to pre-approve Nurtec ODT. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Nurtec ODT 
tablet.  
 Benefits for Nurtec ODT 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 pay for the FoundationOne CDx (F1CDx) testing provided on November 18, 
2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on November 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to 
the enrollee on November 11, 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 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. 
 
 
 The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0673, E0675) provided to the 
enrollee on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213 x 8) provided from September 21, 
2021, through December 14, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided in this case are not 
payable as you have exhausted the allowable benefit.   
 
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. Additionally, the Plan contract covers up to 20 
routine chiropractic visits per plan year.  
 
The Plan contract states that up to 20 routine chiropractic visits are covered per plan year.  However, these 
services were previously provided and paid for by the Plan; therefore, the benefit has now been exhausted. 
Therefore, we decided that the Plan does not have to pay for the office visits (99213 x 8) provided from 
September 21, 2021, through December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee told you they have Medicare. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not 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 visit provided on January 27, 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 outpatient hospital services provided on February 1, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services should be covered as 
you disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as 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 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 outpatient hospital services provided on February 
1, 2022 by an out-of-network (OON) provider.