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

 
We decided that the Plan does not have to pay for the lab services provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered when provided OON without prior authorization. 
 
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 the lab services provided on May 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda 20mg tablets. 
 
You asked the Plan to pre-approve the Latuda tablets. You say that this drug is medically necessary treatment. 
The Plan denied your request. The Plan says this oral drug cannot be covered by Part B. The request must be 
sent to the Part D plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Latuda 20mg tablets.  
 
Benefits for the Latuda tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies rendered on June 10, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 electrical stimulator supplies rendered on June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (82728, 83540, 83550, 84443) provided on 
August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the physician did not provide correct diagnosis 
codes. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until August 18, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services (82728, 83540, 83550, 84443) provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81292, 81206, 81295, 
81162) provided on March 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. This service is not 
supported by the procedure codes billed on this claim; therefore, it is not allowed. As stated in The Centers for 
Medicare & Medicaid Services (CMS); National Correct Coding Initiative Coding Policy Manual for Medicare 
Services; Chapter X "If a laboratory procedure produces multiple reportable test results, only a single 
HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service." 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81292, 
81206, 81295, 81162) provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service October 22, 
2021. 
 
You asked the Plan to pay for procedure code 83789. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 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 83789 
is a column II code to column I code G0480. 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 83789 billed for date of service October 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 88108. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 88108 is bundled into payment for code 88189. 
 
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 88108 
is a column II code to column I code 88189. 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 88108 billed for date of service May 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast(s). 
 
You asked the Plan to pre-approve the breast MRI. You say that it is felt that this imaging would be beneficial 
at this time. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the breast MRI. Our reviewer says that 
the requested imaging is not considered medically reasonable and necessary at this time. Our physician 
reviewer found the record indicates that the enrollee has a distant history of ductal carcinoma in situ breast 
cancer. metastatic to brain. The record indicates that the enrollee underwent mammogram in June 2022 that did 
not demonstrate any areas of concern. The record does not indicate that the enrollee cannot be surveilled using 
mammography. The requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not 
satisfied. 
 
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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the breast(s).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic 
spine. 
 
You asked the Plan to pre-approve the MRI of the spine. You say that it is felt that this imaging should be 
included to see if spinal issues are causing the pain. The Plan denied your request. The Plan says the services 
denied correctly as they are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI of the spine. Our reviewer says 
that the requested imaging is not medically reasonable and necessary in this case. Our physician reviewer found 
the record indicates that the enrollee has abdominal pain and pain that radiates from the flank to upper 
abdomen. The record does not indicate any red flag symptoms or the presence of any neurologic abnormalities. 
The record indicates that the provider has requested other testing to determine the cause of the enrollee's 
symptoms. The requested service is not medically necessary and reasonable for the diagnosis and treatment for 
the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied.  
 
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 MRI of the spine have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 1, 
2022 to April 30, 2022. 
 You asked the Plan to pay for SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee had a medical status change in 
February 2022 and after hospitalization. However, there is no documentation to show that the enrollee required 
daily skilled services in the period of time at issue in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 1, 2022 to April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on April 28, 
2022.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99153 has a PC/TC indicator of three (3), for a technical component only code as defined in 
Medicare Claim Processing Manual Chapter 23, in the 50.6 - Physician Fee Schedule Payment Policy Indicator 
File Record Layout. As CPT code 99153 is a technical component only code, it should be reported by a MAC 
Part A or B hospital setting. the member was in an Outpatient Hospital facility setting on April 28, 2022, at the 
hospital; therefore, we find the Medicare rule for payment of this claim has not been met Therefore, we decided 
that the Plan does not have to pay for moderate sedation services (99153) provided on April 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 27, 2022 to 
June 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 May 27, 2022 to June 
25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum-assisted socket system. 
 
You asked the Plan to pre-approve a vacuum-assisted socket system. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that socket replacements are considered reasonable and 
necessary if there is adequate documentation of functional and/or physiological need. 
 
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 vacuum-assisted socket system. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's current 
transfemoral prosthesis requires replacement and cannot be repaired. The enrollee requires a transfemoral 
prosthesis for mobility and accomplishing his daily activities. This a K3 level ambulator and can ambulate with 
variable cadence and on uneven terrain. The enrollee has been using a vacuum suspension system for his 
prosthesis since his amputations in December of 2012. He has an increased need for proper suspension of his 
socket given that he also has a right sided transtibial amputation and experiences volume fluctuation with a 
medical history of chronic kidney disease. Therefore, the vacuum suspension system for the enrollees 
replacement prosthetic socket is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vacuum-assisted socket system have been met. Therefore, we decided that the 
Plan has to pre-approve a vacuum-assisted socket system.  
 
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 the hereditary cardiomyopathy genomic sequence analysis 
panel (81439) provided on July 26, 2022. 
 
You asked the Plan to pay for the hypertrophic cardiomyopathy panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this service is excluded to confirm an established 
diagnosis or on individuals already diagnosed with cardiomyopathy to identify family members at risk 
 
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 test at issue in this appeal, the hypertrophic cardiomyopathy panel, 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 hereditary cardiomyopathy genomic sequence analysis panel (81439) provided on 
July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a stair lift (E0627) and an elevator permit (E1399) 
provided on April 11, 2022. 
 
You asked the Plan to reimburse you for a stair lift and an elevator permit. You say that the claim was denied 
due to lack of prescribed need. You have included documents confirming an order for the lift. The Plan denied 
your request. The Plan says the requested provider is not a Medicare certified provider. Services are not 
covered if the provider does not participate in 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. The Plan has confirmed that there are 9 Medicare certified providers within 10 miles of your home. 
Therefore, we decided that the Plan does not have to reimburse you for a stair lift (E0627) and an elevator 
permit (E1399) provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81275, 81206, 81210, 
81235) provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. This service is not 
supported by the procedure codes billed on this claim; therefore, it is not allowed. As stated in The Centers for 
Medicare & Medicaid Services (CMS); National Correct Coding Initiative Coding Policy Manual for Medicare 
Services; Chapter X "If a laboratory procedure produces multiple reportable test results, only a single 
HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service." 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81275, 
81206, 81210, 81235) provided on February 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing services provided on April 14, 2022. 
 
You asked the Plan to pay for nursing services. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says this claim was submitted with an 
inappropriate POS code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
We find that the POS code submitted on this claim, POS code 32 (nursing facility) is not supported in the 
medical record. Specifically, the claim submitted by the facility used POS code 31 (skilled nursing facility). 
These POS codes should match. Based on this information, we decided that Medicare rules for coverage of 
nursing services have not been met. Therefore, we decided that the Plan does not have to pay for nursing 
services provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., TENS, 
NMES) (A4595) provided June 10, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that according to the enrollee's 
prescription, the prescribing physician recommends an extended/ lifetime use of equipment as they are 
diagnosed with chronic pain and compromised mobility without the option for surgical correction. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 
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 order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider's 
office indicated and verified that the item was not ordered 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 electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) 
provided June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of brow defect. 
 
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested procedure is considered cosmetic. 
 
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 repair. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this surgery would be considered cosmetic. The marginal reflex distance (MRD) is not documented 
to be less than 2mm and is not supported by the photos provided to be less than 2mm. The visual fields 
provided are unreliable and do not demonstrate a 12-15 degree superior field loss that is improved with 
taping. None of the criteria have been met. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the repair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve repair of brow defect.