Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on December 
22, 2021. 
 
You asked the Plan to pay for the DME. You say that you need a denial so that you can bill Medicaid. The Plan 
denied your request. The Plan says the DME was not billed with the correct modifier. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records 
show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for 
durable medical equipment (DME) provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 10, 2021. 
 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on July 26, 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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific 
criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has multiple pulmonary 
nodules suspicious for metastatic disease. A biopsy revealed epithelioid hemangioendothelioma. It has not been 
demonstrated that the enrollee is a candidate for further treatment with a drug that is either Food and Drug 
Administration (FDA)-approved for the enrollee's cancer, or has an National Comprehensive Cancer Network 
(NCCN) 1 or NCCN 2A recommendation for the enrollee's cancer, and the FDA-approved indication or NCCN 
recommendation is based upon information about the presence or absence of a genetic biomarker tested for in 
the Guardant360 assay, and that tissue-based CGP is infeasible. The testing was therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 panel rendered on July 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on April 6, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
 CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records provided for review did 
not otherwise support provision of a nerve conduction study. There was no recording via surface electrodes of 
stimulation. Rather, this code was submitted in the context of pedicle screw testing which does not meet the 
definition of or technical requirements for provision of a nerve conduction study. Therefore, CPT 95907 cannot 
be said to have been supported by the records provide. As the nerve conduction study was not actually 
performed, CPT 95885 would also not have been necessary. This would not have been the correct and proper 
code to submit for the services provided. Finally, in terms of CPT 95999, for train of four testing - this service 
is inherent to the provision of electromyography (EMG). It is not otherwise generally considered to be a 
separately reimbursable service (with regards to coding). This service cannot be said to have been supported. 
 
We looked at this coder'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 pay for neurophysiology services provided to the enrollee on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical provider home visit (99350) provided on February 
21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been 
met. 
 
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 medical provider home visit (99350) provided 
on February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy (29824, 29826, 29827, 29828) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs this procedure now and 
waiting could cause more damage to the shoulder. The Plan denied your request. The Plan says that the 
requested service is not medically necessary for the enrollee's clinical condition because he has not tried 6 
weeks of non-operative treatment and demonstrated lack of improvement. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of at least 6 weeks of conservative measures to include physical therapy. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder arthroscopy (29824, 29826, 29827, 
29828) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, the measurement of post-voiding residual 
urine and/or bladder capacity by ultrasound, and laboratory services provided on October 22, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit, the measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound, and laboratory services. You say that the enrollee presented his Medicare cared and did 
not mention any other coverage. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider, and there is no referring provider involved in these services. The Plan also says they did 
not authorize any services for this provider. 
  
 
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 an office visit, the measurement of post-voiding 
residual urine and/or bladder capacity by ultrasound, and laboratory services provided on October 22, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two prosthetic legs for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for a new/replacement prosthesis with K2 functional level foot component 
does not meet Medicare criteria for being reasonable and 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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal any objective treating medical physician or treating medical provider 
progress notes supporting the need for these legs including the patient's functional level and physician 
documented medical status with comorbidities. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve two prosthetic legs for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810, 95811). 
 
You asked the Plan to pre-approve the sleep study. You say that the service is necessary. The Plan denied your 
request. The Plan says the sleep testing 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 sleep study. Our reviewer says that 
the requested sleep study is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate there is a specific indication for repeating a sleep 
study at this time to justify repeat testing. Therefore, the reviewer found that the requested sleep study is not 
considered 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 the sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a polysomnography (95810, 95811).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on February 23, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 computed tomography (CT) of the head or brain (70450) 
provided on February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gel-One injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not tried and failed Durolane, Monovisc, or Synvisc-One 
 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 injection. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Gel-One injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia with intestinal malabsorption. The documentation does not 
support that the enrollee has tried and failed Infed (iron dextran) and Venofer (iron sucrose). Based on the 
medical records provided and the Medicare-approved major drug compendia there is no indication that the 
plan's required drug(s) would likely be less effective and/or likely have adverse effects for 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic continuous glucose 
monitor (CGM) device (K0553). 
 
You asked the Plan to pay for the CGM device supply allowance. You say that you have attached all 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the records 
do not support the billed service. 
 
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, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, neither the packing/shipping information, nor 
proof of delivery document matches the date of service for the claim. The packing/shipping information listed 
December 7, 2021, as the shipping date and the delivery confirmation from the United States Postal Service 
(USPS) lists December 10, 2021, as the delivery date. The date of service for the claim is December 8, 2021. 
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 supply allowance used with a therapeutic 
continuous glucose monitor (CGM) device (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Ondansetron.  
 
 
 
 Benefits for Ondansetron 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services you received from a Licensed Marriage and 
Family Therapist (LMFT) on January 13, 2022. 
 
You asked the Plan to pay for the LMFT services. You say that this was an ongoing therapy session and you 
would appreciate consideration of this bill. The Plan denied your request. The Plan says this provider is not 
valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain provider types are eligible to provide 
mental health services to Medicare enrollees.  Licensed Marriage and Family Therapists are not Medicare-
eligible providers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services you received from a Licensed Marriage and Family Therapist (LMFT) on January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the services are medically necessary. The 
Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had prior therapy. The documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The reviewer found that the enrollee has been trained in a home exercise program. 
The reviewer found that the requested services are not part of a maintenance program, and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the reviewer 
found that additional PT visits are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on March 3, 2022. 
 
You asked the Plan to pay for the refraction. You say that you have diabetes and see this doctor once a year. 
You say that you cannot afford this charge, and this should be a paid visit. The Plan denied your request. The 
Plan says eye refractions are only covered if performed by a participating provider and performed as a routine 
screening.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a refraction when performed during a routine exam with a participating vision care 
provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Specifically, the refraction was not performed during a routine 
eye exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on March 3, 
2022.