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

 
We decided that the Plan does not have to pre-approve sclerotherapy of telangiectasia and incompetent veins 
(36470). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are appealing the previously 
denied sclerotherapy. Please see attached detail letter of medically necessity from July 13, 2022. The Plan 
denied your request. The Plan says the Medicare medically necessary criteria has 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not meet coverage criteria. For sclerotherapy to be considered medically necessary there has to be evidence that the enrollee has continued symptoms despite 
conservative care at least 6 weeks following elimination of associated truncal vein reflux. A rationale for this is 
that many patients will experience resolution of the symptoms with truncal reflux treatment alone, rendering 
the additional sclerotherapy unnecessary. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sclerotherapy of telangiectasia and incompetent veins (36470).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on April 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging.  Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic footwear received on January 11, 2022, to 
February 1, 2022. 
 
You asked the Plan to pay for the orthopedic footwear. You say that one of your legs is shorter than the other. 
These shoes alleviate your lumbar spine pain. The Plan denied your request. The Plan says the items are not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the orthopedic footwear received on 
January 11, 2022, to February 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment for ambulance transportation provided on 
March 24, 2022. 
 
You asked the Plan to waive the $100 copayment for ambulance transportation. You say that you should not be 
responsible for this copayment because you needed to be transferred by ambulance. The Plan denied your 
request. The Plan says the copayment has been applied 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 a $100 
copayment for ambulance transportation.  
 
 
 
 
 
 
 You have been asked to pay a $100 copayment for ambulance transportation. Ambulance transportation falls 
within the Ambulance 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 $100 copayment 
for ambulance transportation provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift with chair and sales tax received on November 
23, 2021. 
 
You asked the Plan to pay for the seat lift with chair and sales tax. You say that medical suppliers had a 2-3 
month back order. The Plan denied your request. The Plan says the item is not a covered benefit when provided 
by a provider that does not take 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 the seat lift with chair and sales tax 
received on November 23, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 21, 
2022. 
 
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. 
 
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 January 21, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for medical supplies provided on April 13, 2022. 
 
You asked the Plan to pay for medical supplies. You say that you were told that your request had been 
approved. The Plan denied your request. The Plan says that the denial of payment for these supplies is correct, 
because authorization is required for these supplies and was not obtained. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says that authorization is required for the billed medical supplies. 
However, your contract with the Plan does not state that authorization is required for durable medical 
equipment (DME) and related supplies, only that authorization may be required. Without further specification, 
the Plan contract does not clearly establish that prior authorization is a requirement for coverage of the billed 
medical supplies. Therefore, the Plan has not shown that its decision to deny payment for these supplies is 
correct or justified according to Medicare rules and your contract with the Plan. Therefore, we decided that the 
Plan has to pay for medical supplies provided on April 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve ESI services. You say that the requested injection services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's response to the most recent back injection 
at 3 months is needed to meet the rules for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI services are only considered medically 
necessary if the medical records document at least 50% sustained improvement in pain relief and/or 
improvement in function for at least three months.  
 
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 ESI services. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain 
with weakness and tingling in both lower extremities. The pain is mild and constant.  The pain is aggravated by 
movement. Magnetic resonance imaging (MRI) of the lumbosacral (LS) spine on September 20, 2021, 
demonstrated severe facet arthropathy at L3-L4 and L4-L5, degenerative disc disease and spinal stenosis, 
severe at L3-L4 and moderate at L4-L5; moderate neuroforaminal narrowing most severe at the left L4-L5 and 
moderate at other levels.  He has been treated with medical therapy, physical therapy, and epidural steroid 
injections 3 times. The enrollee had an epidural steroid injection on May 18, 2022. There is no documentation 
of the percentage of pain relief at 3 months since the injection. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESI services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injection (ESI) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided April 4, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this test was 
medically necessary and used to help determine treatment options. The Plan denied your request. The Plan says 
that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making 
in the clinical management of the patient and will be denied automatically as not medically necessary. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case the Plan denied the targeted genomic sequence analysis panel on the 
basis that it is non-covered by Medicare. Specifically, the Plan stated that Medicare Local Coverage Article: 
Billing and Coding: Molecular Pathology Procedures (A56199) states that genetic testing procedures 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient and will be denied automatically as not medically necessary. We reviewed the article and found 
that this exclusion applies to codes listed in Group 3 in the article. Code 81455 is not listed in Group 3. Thus, 
this exclusion does not apply to the service at issue. Therefore, we decided that the Plan has to pay for the 
targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA 
analysis when performed, 51 or greater genes (81455) provided April 4, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization program (PHP) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be safely managed on an outpatient basis by recommencing visits with a 
psychiatrist to initiate/optimize pharmacotherapy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was not showing any dangerousness to self or others and has not been exhibiting severe 
psychological or psychiatric impairment requiring this level of care. The enrollee was not showing  any 
perceptual disturbance, psychosis or aggressive behaviors. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the partial hospitalization level of care rather than a lower level of care as 
she did not have any suicidal or homicidal thoughts or behavioral disturbance and her symptomatology could 
be treated at a lower level of care. The health plans denial of continued partial hospitalization treatment for the 
dates in question appears appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial hospitalization program (PHP) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses provided on March 27, 2022. 
 
You asked the Plan to pay for the knee orthoses. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation did not include a valid proof of delivery. 
 
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 proof of delivery for the item provided in this case. 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 the knee orthoses provided on March 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a mohs micrographic technique performed 
on April 13, 2022. 
 
You asked the Plan to reduce the copayment for the mohs micrographic technique. You say that you never paid 
more than $50 for this procedure in the past. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 a $395 
copayment for surgery services at an outpatient hospital.  
 
 
 
 
 
 
 You have been asked to pay a $395 copayment for the mohs micrographic technique. The mohs micrographic 
technique is considered a surgical procedure and 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 reduce the copayment for a mohs micrographic technique performed on April 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the records support that this was performed 
by the provider and the claim denied as a duplicate in error. You say that the claim should be reprocessed for 
reimbursement according to the contract. 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 March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitrectomy recovery equipment received on March 4, 
2022. 
 
You asked the Plan to pay for the vitrectomy recovery equipment. You say that you disagree with the Plan's 
denial The Plan denied your request. The Plan says the item received is not a covered benefit when provided by 
a non-certified retailer. 
 
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 the vitrectomy recovery equipment 
received on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multianalyte assay procedure with algorithmic analysis 
provided on March 8, 2022, by an OON provider. 
 
You asked the Plan to pay for a multianalyte assay procedure with algorithmic analysis. You say that we are 
requesting reconsideration of the denial for the test because this laboratory is the only certified lab to run this 
test. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 a multianalyte assay procedure with algorithmic 
analysis provided on March 8, 2022, by an OON provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services (A0431-IH, A0436-IH) provided on February 
13, 2022. 
 
You asked the Plan to pay for air ambulance services. You say that the service at issue was medically 
necessary. The Plan denied your request. The Plan says that the enrollee did not meet criteria for coverage. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for air ambulance services. Our reviewer says 
that the service was medically necessary. Our physician reviewer found the documentation indicates that due to 
the enrollee's injuries and cardiac history transfer to a trauma center was medically indicated. The review 
indicates that the documentation did support that the enrollee suffered from an illness or injury that 
contraindicated transportation by any means other than ambulance. The documentation did support that the 
enrollee's condition was such that the time needed to transport an enrollee by ground, or the instability of 
transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. 
The documentation did support that the transferring hospital did not have adequate facilities to provide the 
medical services needed by 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 air ambulance services have been met. Therefore, we decided that the Plan has 
to pay for air ambulance services (A0431-IH, A0436-IH) provided on February 13, 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.