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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
5, 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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe obesity and was 
recently hospitalized with pneumonia, sepsis, and gastrointestinal (GI) bleeding. Arterial blood gas (ABG) 
studies were consistent with acute on chronic hypercarbic respiratory failure. A diagnosis of chronic 
obstructive pulmonary disease (COPD) is mentioned but the records do not support this. There are no 
pulmonary function tests, no past history of COPD, and the enrollee was not being treated for COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The services are therefore not reasonable 
or 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 these services 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 laboratory services related to end-stage renal disease 
(ESRD) provided on September 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, ferric carboxymaltose, 1 mg (J1439). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not have a history of failure, contraindication, or intolerance to 
the formulary alternatives. This is not a continuation of therapy in the past 365 days. The enrollee does not 
meet the Part B Step Therapy requirements for the requested injection. 
 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 looked at the file and Medicare rules. The records show the product requested has a Part B Step Therapy 
requirement and it is a non-preferred drug/product for the enrollees condition. The plan benefits say you may 
have to try another drug that treats the enrollee's condition before you try the drug that was requested. The 
provider has noted that the enrollee will be switched to a preferred drug. Based on this information, we decided 
that Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an injection, ferric carboxymaltose, 1 mg (J1439).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the bilateral duplex imaging of the extremities 
provided on June 27, 2022. 
 
You asked the Plan to pay for the duplex scan interpretation. You say that this procedure is separate and 
distinct and should be paid. The Plan denied your request. The Plan says that observation codes should not be 
used when signs or symptoms related to the suspected condition are present. The Plan indicates that review of 
documentation indicates the enrollee presented to rule out deep vein thrombosis (DVT). Documentation does 
not indicate the reason DVT is suspected or why it is being ruled out. 
 
The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM coding guidelines must be followed 
for billing of medical services. The rules say that unspecified and observation codes should only be used in 
specific situations noted in the Medicare rules section of this decision.  
 
We looked at the file and Medicare rules. The Plan indicates that the claim should report the signs or symptoms 
that led to the suspicion of DVT or why it needs to be ruled out. However, this claim is for the services of the 
interpreting physician, not the physician treating the enrollee. The record that is available does not indicate the 
signs/symptoms, or the treating physician's rationale for providing this imaging. This imaging was read for a 
hospital inpatient. The radiologist may not have been informed of more than the fact that this was ordered to 
rule out DVT, which was, in fact, ruled out. We find that the reported diagnosis code accurately reflects the 
reason for this testing insofar as can be determined from the records available. Based on this information, we 
decided that Medicare rules for coverage of the duplex scan interpretation have been met. Therefore, we decided that the Plan has to pay for the interpretation of the bilateral duplex imaging of the extremities 
provided on June 27, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA Disc allograft. 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 follows Medicare rules. Medicare rules say that effective for services performed on or after 
September 29, 2008, the Centers for Medicare and Medicaid Services has determined that TIPs are not 
reasonable and necessary for the treatment of low back pain. 
 
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 VIA Disc allograft. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found Via Disc allograft is experimental. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a VIA Disc allograft intervertebral disc augmentation procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the dental 
services on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oxygen concentrator, single delivery port, capable of 
delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided June 29, 
2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you lived in a senior living facility and 
your daughter bought a portable oxygen concentrator 2 months ago. The Plan denied your request. The Plan 
says the equipment was purchased from a supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for Oxygen concentrator, single delivery 
port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) 
provided June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dental extraction (D7210) provided on 
August 10, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
  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.    
 
You have been asked to pay $50 co-payment for 2 tooth extractions ($25 x 2 = $50) provided on August 10, 
2022. This item/service falls within the dental services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. 
 Therefore, we decided that the Plan does not have to waive the copayment for a dental extraction (D7210) 
provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing (80307) provided July 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached all records you have 
showing that these services were ordered by the enrollee's physician. The Plan denied your request. The Plan 
says does not meet Medicare NCD/LCD criteria. 
 
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 laboratory services have been met. 
Additional records were needed to determine medical necessity and how the enrollee came to the servicing 
provider. The records show that the Plan made multiple attempts to obtain the needed records from the provider 
without success. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing 
(80307) provided July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a dental cleaning (D4342) provided on October 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were informed prior to the services that they would be covered. The Plan denied your 
request. The Plan says that the services denied correctly as they do not fall within your dental benefits. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Your contract with the plan shows that there is coverage for dental cleanings twice per year 
and there is no evidence showing your benefit for the requested item or service was previously exhausted. 
Therefore, we decided that the Plan has to pay for the dental cleaning (D4342) provided on October 6, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 13, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that this provider comes to your assisted living 
facility. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 items/services at issue in this appeal. The Plan has a network provider located 
1.9 miles from your residence. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be 
provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three-dimensional (3D) rendering of an approved 
computed tomography (CT) scan of the sinuses. 
 
You asked the Plan to pre-approve the 3D rendering of the CT scan. You say that 3D rendering is medically 
necessary in this case. The Plan denied your request. The Plan says there is insufficient support that 3D 
rendering is needed. 
 
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 3D rendering of the CT scan. Our 
reviewer says that the requested 3D rendering not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 71-year-old man with a diagnosis of Chronic sinusitis, 
unspecified. He has had recurrent nasal congestion, right worse than left, for 30 years. The treatment plan 
included topical nasal sprays, as well as 3 weeks of antibiotics and a course of steroids. The enrollee was to 
return in 4 weeks, when a CT scan of his sinuses would be performed. 
 
 3D rendering of the CT scan of the sinuses is not considered medically reasonable and necessary for the 
enrollee in this case. The documentation does not support that the necessary information cannot be obtained by 
traditional two-dimensional imaging and is critical to the clinical management of this 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 the 3D rendering of the CT scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve three-dimensional (3D) rendering of an approved computed tomography 
(CT) scan of the sinuses.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 15, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 15, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. 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. 
 
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 Supartz. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plans additional required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Supartz is not approved, as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.