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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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, for 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 April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided August 19, 2022. 
 
You asked the Plan to pay for the back brace. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the item billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician orderor relevant medical records which support medical necessity 
for the supplies provided in this case. The order was not signed by the physician. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for a back brace (L0650) provided August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 04, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
October 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OrthoFix Trinity Elite Allograft. 
 
You asked the Plan to pre-approve OrthoFix Trinity Elite Allograft. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve OrthoFix Trinity Elite Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for spondylolisthesis of the lumbar region. 
The enrollee presented with back pain without radicular symptoms. The exam reveals paraspinous tenderness 
and spasms at L4-5-S1. There is increased pain with extension and facet loading. Straight leg raise causes back 
pain bilaterally. There is limited published, large-scale, long-term peer-reviewed literature that shows the 
requested OrthoFix Trinity Elite allograft to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional 
treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception.  Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OrthoFix Trinity Elite Allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve OrthoFix Trinity Elite Allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adcetris (CPT code J9042). 
 
You asked the Plan to pre-approve the medication. You say that the is medically necessary for the enrollee's 
treatment for aggressive systemic mastocytosis. The Plan denied your request. The Plan says the 
documentation does not support that monthly brentuximab with daily midostaurin is supported for treatment for 
aggressive systemic mastocytosis per National Comprehensive Cancer Network (NCCN) guidelines or off label 
use found in literature. 
 
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 the medication. Our physician reviewer 
found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were 
submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Adcetris (CPT code J9042).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with average 
volume assured pressure support and a back-up rate. As stated in the Local Coverage Determination (L33800): 
"Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on April 12, 2022. 
 
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 procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
19 drug classes were tested. 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 definitive drug 
testing rendered on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for eye exams and glasses provided from January 5, 
2022, to August 4, 2022. 
 You asked the Plan to pay the full cost for eye exams and glasses. You say that the first provider misdiagnosed 
you so you should be reimbursed. The Plan denied your request. The Plan says these services processed 
correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. contract states that it covers 1 routine eye exam per year and covers Medicare-covered eye exams 
with a $5 copayment. The Plan will pay up to $200 per year for routine contacts or eyeglasses. 
 
We looked at the file and the Plan's rules. The record shows that the Plan provided coverage for a routine eye 
exam and $200 towards eyeglass on January 5, 2022. You are responsible for the cost of eyeglasses above this 
amount. You are also responsible for a $5 copayment for the diagnostic eye-exam provided on August 4, 2022. 
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. The routine eye exam, or 
refraction, provided on this date is not separately payable as a routine exam previously paid for the earlier date 
of service. Based on this information, we decided that the Plan's rules for coverage of eye exams and glasses 
have not been met. Therefore, we decided that the Plan does not have to pay the full cost for eye exams and 
glasses provided from January 5, 2022, to August 4, 2022.  
 
Your complaint about being misdiagnosed by the first provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 5, 2022, to 
August 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 5, 2022, to August 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala Trio nerve stimulator device. 
 
You asked the Plan to pre-approve Cala Trio nerve stimulator device. 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 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 Cala Trio nerve stimulator device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found 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 Cala Trio nerve stimulator device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Cala Trio nerve stimulator device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services (85025, 82270, 84134, 84443, 
82746, 82607, 83718, 84478, 82465, 83721, 83970, 82306, 82043, 84550, 81001, 81002, 81003, 82962, 80069, 
80074, 80048, 80076, 80053, G2023, G2024, 87635, 36415, P9604, 83880, 82040, 83735, 85610) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve laboratory services. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the enrollee must use network 
providers to get health care and services when there are network providers available. From the records 
received, no medical need is shown as to why the enrollee cannot get this health care/service from a provider in 
her plan 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 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. 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 
laboratory services (85025, 82270, 84134, 84443, 82746, 82607, 83718, 84478, 82465, 83721, 83970, 82306, 
82043, 84550, 81001, 81002, 81003, 82962, 80069, 80074, 80048, 80076, 80053, G2023, G2024, 87635, 
36415, P9604, 83880, 82040, 83735, 85610) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 24, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided on June 30, 2022. 
 
You asked the Plan to pay for Infrared light therapy. The Plan denied your request. The Plan says Infrared 
therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on June 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve a computerized tomography (CT) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
services requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computerized tomography (CT) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the CT scan is 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computerized tomography (CT) scan have been met. Therefore, we decided 
that the Plan has to pre-approve a computerized tomography (CT) scan.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. 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, for 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 April 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine transport beyond the Plan's 50-mile trip limit. 
 
You asked the Plan to pay for the routine transport beyond the Plan's mileage limit. You say that you need 
transportation to an upcoming appointment. The Plan denied your request. The Plan says this trip exceeds the 
mileage limit in your transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles of driving distance each one-way trip. 
 
We looked at your request, the records in the case file, and the rules. The requested trip exceeds 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
transport beyond the Plan's 50-mile trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065) 
for teeth numbers 13 and 14, a prefabricated abutment (D6056) for teeth numbers 13 and 14, bone replacement 
graft (D7953) for tooth number 14, guided tissue regeneration (D4266) for teeth number 14, and a surgical 
placement of an implant body (D6010) for teeth numbers 13 and 14. 
 
You asked the Plan to pre-approve an implant supported porcelain/ceramic crown (D6065) for teeth numbers 
13 and 14, a prefabricated abutment (D6056) for teeth numbers 13 and 14, bone replacement graft (D7953) for 
tooth number 14, guided tissue regeneration (D4266) for teeth number 14, and a surgical placement of an 
implant body (D6010) for teeth numbers 13 and 14. You say that you have an infection on your teeth, and you 
have great pain when eating/chewing food. You also say you need to get the extraction and implant done to be 
able to properly eat again. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported porcelain/ceramic crown (D6065) for teeth numbers 13 and 14, a prefabricated abutment 
(D6056) for teeth numbers 13 and 14, bone replacement graft (D7953) for tooth number 14, guided tissue 
regeneration (D4266) for teeth number 14, and a surgical placement of an implant body (D6010) for teeth 
numbers 13 and 14.