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

 
We decided that the Plan does not have to pay for the eye injection provided on December 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim should be paid as medically 
necessary. The Plan denied your request. The Plan says you did not receive emergency care. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   We looked at the file, and Medicare rules. The services at issue were not urgent or emergent. The need for 
services was known prior to leaving the Plans service area. The Plan did not pre-approve the services at issue. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the eye injection provided on December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service January 20, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service January 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polysomnography (CPT code 95810). 
 
You asked the Plan to pre-approve the polysomnography. You say that the service is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 the polysomnography. Our physician 
reviewer found the reviewed documentation indicates that the guidelines state a repeat sleep study is not 
reasonable or medically necessary for evaluation for a hypoglossal nerve stimulator and states that a 
hypoglossal nerve stimulator is only covered for patients with a body mass index (BMI) of less than thirty-five and your current body mass index (BMI) is thirty-eight. The review has determined that the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the polysomnography (CPT code 95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a high frequency chest wall 
oscillation device (HFCWOD). 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for a high frequency chest wall oscillation device (HFCWOD). Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has cystic 
fibrosis, bronchiectasis, or a neuromuscular disease. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93451 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 93451. The Plan denied your request. The Plan says payment for 
code 93451 is bundled into payment for code 93505.  
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 93451 
is a column II code to column I code 93505. 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 93451 billed for date of service February 16, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound coded 76706 provided on June 7, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The ultrasound at issue in this appeal was billed with diagnosis codes Z13.6 (encounter for screening for 
cardiovascular disorders) and I71.4 (abdominal aortic aneurysm, without rupture). This means the ultrasound 
was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76706 provided on June 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the records support the medical necessity of 
the services. 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 86077 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 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 86077 billed for date of 
service May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the spinal cord stimulator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a spinal cord 
stimulator. 
 
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 a spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for a spinal cord stimulator. Our physician reviewer found the 
enrollee has chronic low back pain and lumbar radiculopathy. No prior spine surgery or post herpetic neuralgia. 
He takes Duloxetine, Diclofenac, Lyrica, and uses medical marijuana. He has psychological clearance for a 
spinal cord stimulator trial. The enrollee does not have an evidence-based indication for a spinal cord 
stimulator trial. The request is 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the billed code cannot be verified. 
 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not document the total time critical care services were 
furnished. Based on this information, we decided that Medicare rules for coverage of the billed service have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of 
service May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0849). 
 
You asked the Plan to pre-approve a group 3 power wheelchair (K0849). You say that the requested group 3 
power wheelchair (K0849) is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for a group 3 power wheelchair (K0849). 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules also say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. 
 
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 group 3 power wheelchair (K0849). 
Our reviewer says that the enrollee does not meet criteria for a group 3 power wheelchair (K0849). Our 
physician reviewer found the enrollee has a mobility deficit. She ambulates with a walker in the home. The 
request for a Group 3 power wheelchair K0849 exceeds the enrollee's medical needs per Local Coverage 
Determination (LCD): Power Mobility Devices L33789. The enrollee does not have myopathy. The enrollee 
does not have a congenital skeletal deformity. The documentation does not indicate that the enrollee has a 
neurological condition that requires a Group 3 power wheelchair. 
 
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 group 3 power wheelchair (K0849) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0849).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in PS with Safety Tidal 
Volume mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 home ventilator. Our physician 
reviewer found this enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) 
during sleep. However, Medicare does not cover a home ventilator when used as BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 22, 
2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $320 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $320 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on 
August 10, 2022. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $75 copayment for diagnostic mammogram. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic mammogram provided on August 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 25, 2022, to May 
20, 2022. 
 
You asked the Plan to pay for home health services. You say that a Notice of Admission was previously 
submitted. The Plan denied your request. The Plan says this claim was not billed with the correct admission 
date. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of 
Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first 
period of continuing care in 2022.  The HHA should submit that admission date on all subsequent claims until the beneficiary is discharged and another NOA is required.  
 
We looked at the file and Medicare rules. The claim for the services at issue was not billed with the admission 
date listed on the NOA. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided from April 25, 2022, to May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve the Vabysmo. You say that Vabysmo is medically necessary. The Plan 
denied your request. The Plan says a failed trial of Lucentis is required before alternatives like Vabysmo can be 
considered. 
 
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 the Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the records do not show that the enrollee 
has tried and failed the plan-preferred drug, or that is unsafe or ineffective for this enrollee. While the records 
show the enrollee did receive a Lucentis injection, the records do not show the treatment failed. 
 
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 Vabysmo have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the Prostate 
(code 0421T). 
 
You asked the Plan to pre-approve Transurethral Waterjet Ablation of the Prostate. You say that Transurethral 
Waterjet Ablation of the Prostate is medically necessary. The Plan denied your request. The Plan says 
Transurethral Waterjet Ablation of the Prostate does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 Transurethral Waterjet Ablation of the 
Prostate. Our reviewer says that Transurethral Waterjet Ablation of the Prostate is not medically necessary. Our 
physician reviewer found that the requested Transurethral Waterjet Ablation of the Prostate does not meet the 
Medicare LCD coverage criteria. A urinary flow rate is not provided in the medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Transurethral Waterjet Ablation of the Prostate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Transurethral Waterjet Ablation of the Prostate 
(code 0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206), a periodic 
oral evaluation (D0120), an adult prophylaxis (D1110), an intraoral - periapical first radiographic image 
(D0220) for tooth number 02, and an intraoral - periapical each additional radiographic image (D0230) for 
teeth numbers 14 and 30 provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that nothing was paid. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a topical application of fluoride varnish (D1206), a periodic oral evaluation (D0120), an adult 
prophylaxis (D1110), an intraoral - periapical first radiographic image (D0220) for tooth number 02, and an 
intraoral - periapical each additional radiographic image (D0230) for teeth numbers 14 and 30 provided on 
May 3, 2022.