Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cancer treatment services provided on December 20 to 
December 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for cancer treatment services. 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 cancer treatment services provided on December 
20 to December 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 a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found there are no medical records other than the order/request for the device. You have a 
diagnosis of chronic obstructive pulmonary disease, but there are no pulmonary function tests to assess severity 
or arterial blood gases (ABG) to document chronic CO2 retention. Bilevel positive airway pressure (Bipap) 
with average volume-assured pressure support (AVAPS) has apparently not been tried. You have reportedly had a home ventilator since 2020, but there is no documentation to assess compliance. Medicare does not cover 
a home ventilator when used as bipap. Therefore, you do not meet criteria for the requested device. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kit received on January 15, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the COVID-19 test kit. You say that you really needed the tests when you bought 
them. The Plan denied your request. The Plan says the items received are not a covered benefit. 
 
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. 
 
Review of the file shows that you received COVID-19 test kits on January 15, 2022. The Plan did not start 
covering COVID-19 test kits from network providers until February 15, 2022. This means you received the test 
kits before the at-home COVID-19 benefit went into effect. 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 COVID-19 test 
kit received on January 15, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the out-of-network urgent care visit on July 12, 2021. 
 
You asked the Plan to pay for urgent care visit. You say that you became ill while you were out of state and 
needed to go to urgent care. The Plan denied your request. The Plan says that the provider is not in network and 
no authorization is on file. 
 
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. Specifically, the plan did not send us medical records. You were outside of the 
Plans service area when this service was received. You say that you became ill and needed urgent care. 
Without medical records, we cannot determine whether the service provided constituted urgently needed care. 
Therefore, the Plan has not shown that their decision to deny payment for this visit is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for the out-of-network urgent care 
visit on July 12, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for anesthesia services (00811) provided on October 28, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a necessity for the 
enrollee's care. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the procedure code billed is invalid but does not 
state the cause of invalidity nor suggest how to correct the issue. It is the Plan's responsibility to substantiate its 
denial. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided 
that the Plan has to pay for anesthesia services (00811) provided on October 28, 2021.  
 
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 laboratory services coded 81206, 81275, 81276, and 
81301 provided on October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT codes 81206, 81275, 81276, and 81301 are not supported in the medical record. Specifically, 
when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Review of the file does not support that only one code was billed for the services 
rendered. This means the services were billed incorrectly.  
 
 Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 
81275, 81276, and 81301 provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection (CPT code J7325) and arthrocentesis, aspiration and/or injection, major joint or bursa 
(eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610). 
 
You asked the Plan to pre-approve the services. You say that you started therapy Monday cause your health 
plan suggested it and schedule to go back five (5) more times. You state your knees are almost bone on bone it 
hurts all the time and the shot that acts as a artificial cartilage for each knee needs a shot but the shots are 2,000 
each. The Plan denied your request. The Plan says your records do not show that you have had physical 
therapy, have tried medications, or that the pain you are experiencing is interfering in your daily activities. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures prior to injection. Additionally, there are no imaging 
studies provided and/or noted to corroborate pathology in the left knee. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection (CPT J7325) and arthrocentesis, aspiration and/or injection, major joint or bursa without ultrasound 
guidance (CPT 20610), in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection (CPT code 
J7325) and arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial 
bursa); without ultrasound guidance (CPT code 20610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array. You say 
that the requested spinal cord stimulator implant is medically necessary. The Plan denied your request. The 
Plan says the requested spinal cord stimulator implant does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not 
evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care 
measures. Additionally, it is not clearly documented that he is not a surgical candidate. There are limited large-
scale, long-term references showing the safety and efficacy of spinal cord stimulation in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array, epidural (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 2 very heavy duty, 
patient weight capacity 451 to 600 pounds (CPT code K0808). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says this wheelchair is not covered. 
 
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 DME have not been met. Medicare guidance says That the 
specific type of scooter you requested, the "Group 2 Power Operated Vehicle - K0808, is never covered by 
Medicare. This is because Medicare only covers medical equipment that is needed within the home. The 
scooter that has been requested has added capabilities that are not needed for use in the home. For this reason, 
Medicare never covers this specific type of scooter. Therefore, we decided that the Plan does not have to pre-
approve power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds (CPT 
code K0808).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 pre-approve a SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee did not have sustained pain relief from a prior SCS. There is no rationale for why another SCS will succeed when it failed in the past. The 
request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation services coded 85060 
provided on September 16, 2021. 
 
You asked the Plan to pay for the blood smear interpretation services. You say that you would like the plan to 
reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, the provider billed on the 
claim is not supported by the medical records provided. The documentation shows that a different provider 
provided the services rendered and the Plan had already paid two units of this code to that provider. This means 
this claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
the blood smear interpretation services have not been met. Therefore, we decided that the Plan does not have to 
pay for the blood smear interpretation services coded 85060 provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
 
You asked the Plan to pre-approve the ventilator. You say that the Life2000 will help the enrollee be more 
active in and outside her home and will significantly improve her quality of life. The Plan denied your request. 
The Plan says the records do not support that this device is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has severe bullous emphysema and COPD. There is no arterial blood gas to 
document chronic CO2 retention, so the enrollee does not qualify for ventilatory support during sleep. The 
Life2000 System is not a true ventilator, because it is not able to provide full ventilatory support. There is 
inadequate evidence that this device is beneficial in the treatment of COPD. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies rendered on December 6, 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A6196 and A6402 have a status indicator of P on the Physician Fee Schedule. This 
means that CPT codes A6196 and A6402 are not separately payable. 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 wound care supplies rendered on December 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from December 13, 
2021, to January 23, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that this charge should be covered. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
 
 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 $184 
copayment per day for days 21 through 100 for each Medicare covered SNF stay for 2021 and $188 copayment 
per day for days 21 through 100 for each Medicare covered SNF stay in 2022.  
 
You have been asked to pay a total of $5,315 for the SNF stay. SNF falls within the Skilled nursing facility 
(SNF) 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. Therefore, we decided that the Plan does not have to waive the copayment for SNF care provided from 
December 13, 2021, to January 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anchoring of biceps tendon (CPT code 23430), partial 
removal of collar bone at shoulder using an endoscope (CPT code 29824) and shaving of shoulder bone using 
an endoscope (CPT code 29826). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's doctor's notes do not show they have tried other treatments covered by the 
enrollee's plan (a full course of physical therapy and other non-operative treatments). The Plan states the 
enrollee's doctor's notes do not show why they cannot try other treatments covered by the enrollee's plan; 
therefore, this left shoulder surgery 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested anchoring of biceps tendon (CPT 23430), partial removal of collar bone at 
shoulder using endoscope (CPT 29824) and shaving of shoulder bone using an endoscope (CPT 29826), in this 
case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anchoring of biceps tendon (CPT code 23430), partial removal of collar bone at shoulder 
using an endoscope (CPT code 29824) and shaving of shoulder bone using an endoscope (CPT code 29826).