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

 
We decided that the Plan does not have to pre-approve injection of sclerosant; multiple incompetent veins 
(other than telangiectasia), same leg (CPT code 36471) and endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated (CPT code 
36478). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show they have 
symptomatic, hemodynamically significant peripheral arterial disease in the same leg that varicose vein 
treatment is being requested. 
 
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 physician reviewer 
found the LCD L33575 states that sclerotherapy of varicose veins, or endovenous ablation therapy are 
generally not covered for patients with severe distal arterial occlusive disease. The enrollee in this case has 
severe distal arterial occlusive disease, and the documentation is insufficient to support that the proposed 
procedure is medically necessary in this setting. 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 injection of sclerosant; multiple 
incompetent veins (other than telangiectasia), same leg (CPT code 36471) and endovenous ablation therapy of 
incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein 
treated (CPT code 36478).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately and is 
supported in the medical record. 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 November 11, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 
22, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was evaluated by two physicians in 
the same physician group on the same date of service. The Plan covered one unit of the emergency room services. Further services cannot be paid. Therefore, we decided that the Plan does not have to pay for the 
emergency room (ER) services rendered on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 In this case, we find that CPT code 0037U is not supported in the medical record. Specifically, the next 
generation sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for 
this gene is not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels 
that include the FANCC gene are statutorily excluded service. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories (E2365, K0823) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair with accessories. You say that these items are 
medically necessary. The Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair with accessories (E2365, K0823) 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 the genetic testing provided on October 10, 2021, billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 10, 2021, billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service November 
28, 2021. 
 
You asked the Plan to pay for procedure code 93010. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 36556. 
 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 93010 
is a column II code to column I code 36556. 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 93010 billed for date of service November 28, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the rubber rings broke off and the 
motor is noisy for the current hospital bed the enrollee has. The enrollee's fingers are being poked when 
adjusting the bed and the member is paraplegic. The Plan denied your request. The Plan says the requested item 
is not a covered benefit with Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient therapy session on March 15, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient therapy session. You say that you are not 
responsible for this copayment because you did not receive this service. The Plan denied your request. The Plan 
says you are responsible to pay a $40 copayment for each individual therapy session. 
 
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 $40 
copayment for Outpatient Mental Health Care.  
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for an outpatient therapy session. An outpatient therapy session 
falls within the Outpatient Mental Health Care 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. Records submitted support this service was provided. Therefore, 
we decided that the Plan does not have to waive the copayment for an outpatient therapy session on March 15, 
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 June 10, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately. 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 June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Wheelchair accessory, tray, each (E0950). 
 
You asked the Plan to pay for the tray. You say that the enrollee was given a left sided lap tray back in 2021. 
During the year you were told that it would be resubmitted and it would be considered medically necessary. 
Then in November you received a statement for the cost of the lap tray. The Plan denied your request. The Plan 
says this is a personal comfort and convenience item and is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for Wheelchair accessory, tray, each (E0950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the in-network dermatologists have not been able to help you. The Plan denied your 
request. The Plan says the care being delivered can be provided within the Plan's 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 32557. 
 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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service March 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $175 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $175 for these 
services. 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 the ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on November 13, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral nerve blocks. 
 
You asked the Plan to pre-approve the peripheral nerve blocks. You say that you would like reconsideration 
because the enrollee's headaches are severe and unresponsive to treatment. The Plan denied your request. The 
Plan says this service 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 pre-approve the peripheral nerve blocks. Our 
reviewer says that the enrollee in this case does not have a condition for which nerve blocks have been shown 
to be medically reasonable and necessary. Our physician reviewer found there is insufficient support in the 
medical literature for the requested use. 
 
 
 
 
 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 peripheral nerve blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the peripheral nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion (E0190). 
 
You asked the Plan to pre-approve a positioning cushion. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says the requested item is not a covered benefit in this case. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a positioning cushion (E0190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on February 
21, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the provider and referring 
providers are participating providers with Medicare. The Plan denied your request. The Plan says the enrollee 
went to an out-of-network provider and services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on 
February 21, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2021 billed with 
codes 81206, 81292, & 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 26, 2021 billed with codes 81206, 81292, & 81301.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance and device evaluation (33274) for the 
enrollee. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the enrollee requires a pacemaker to 
help with the function of the enrollee's heart. The Plan denied your request. The Plan says that records do not 
show that the enrollee is in a CMS approved CED study. 
 
The Plan must follow Medicare rules. Medicare limits coverage of leadless pacemakers to those provided 
within a study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, there was no documentation that the leadless 
pacemaker is being provided as part of a Medicare-approved study. This service is not covered unless part of a 
Medicare-approved study. Therefore, we decided that the Plan does not have to pre-approve transcatheter 
insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance and 
device evaluation (33274) for the enrollee.