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

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) (K0553) provided on September 18, 2022.

You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the shipping date or the date or delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record shows that the shipping date of this item was September 9, 2022, and the delivery date was September 14, 2022. Therefore, the date of service billed on this claim, September 18, 2022, does not meet Medicare rules. 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 a therapeutic continuous glucose monitor (CGM) (K0553) provided on September 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on October 9, 2022. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xF testing provided on October 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fitness program with the out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met. Specifically, the Plans contract states that a 
fitness membership is provided with the Plans select fitness provider including access to a nationwide network 
of gyms and fitness locations. However, your request in this case is for a fitness membership with an out-of-
network provider facility. Therefore, we decided that the Plan does not have to pre-approve the fitness program 
with the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that the services are medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the member meets criteria; therefore, the Plan is 
upholding the denial. Multiple attempts were made to obtain medical records, but additional supporting 
documentation was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI have been met. Medical 
records have not been provided. Therefore, we decided that the Plan does not have to pre-approve Special 
Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on August 11, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this code is not separately payable. 
 
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 code 99213 is not supported in the medical record. Specifically, code 99213 is included in 
the global package of code 20611. Based on this information, we decided that Medicare rules for coverage of 
the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit 
(99213) provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for extractions (D7140 and D7210) for tooth #3, #4, #5, #6, #7, #8, #13, 
#14, and #15 provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider is an in-network provider, and the 
claim was filed for the extractions. The Plan denied your request. The Plan says that the denial of payment is 
correct because the benefit limit for the procedures has been reached. 
 
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 specifically did not provide documentation showing that the benefit for 
the dental extractions for each tooth was exhausted and therefore has not substantiated their denial reason. 
Therefore, we decided that the Plan has to pay for extractions (D7140 and D7210) for tooth #3, #4, #5, #6, #7, 
#8, #13, #14, and #15 provided on May 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 
You asked the Plan to pre-approve Ferumoxytol. 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. 
 
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 Ferumoxytol. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-coronary vascular stents/percutaneous transluminal 
angioplasty (PTA) (37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, and 37231). 
 
You asked the Plan to pre-approve non-coronary vascular stents/PTA. 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 PTA is covered when used under certain conditions. 
 
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 non-coronary vascular stents/PTA. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record provided 
is insufficient to establish that the enrollee has an obstructive atherosclerotic lesion that is intended to be treated 
by the provider. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-coronary vascular stents/PTA have not been met. Therefore, we decided 
that the Plan does not have to pre-approve non-coronary vascular stents/percutaneous transluminal angioplasty 
(PTA) (37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, and 37231).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology provided on September 28, 2022. 
 
You asked the Plan to pay for the molecular pathology. You say that the services are a covered benefit under 
Medicare rules. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the molecular pathology 
provided on September 28, 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 November 7, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2022, billed 
with codes 81270, 81279, 81338, and 81219. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
September 9, 2022, billed with codes 81270, 81279, 81338, and 81219.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service August 14, 2021. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88341, 88342, 88360, and 88381 billed for date of service August 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (U0003, U0005) provided July 24, 
2021. 
 
You asked the Plan to pay for the COVID-19 testing. You say that the claim was filed timely. 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 COVID-19 testing was not filed until September 30, 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 COVID-19 testing (U0003, U0005) provided July 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. The Plan denied your request. The Plan says Medicare Part B 
does not usually cover self-administered drugs. 
 
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 Mounjaro.  
 
 
 Benefits for Mounjaro 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan Solution. 
 
You asked the Plan to pre-approve Lumigan. You say that Lumigan has controlled the enrollee's pressures for 
years. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
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 Lumigan Solution.  
 
 
 Benefits for Lumigan 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of lower extremity arteries provided on 
September 27, 2022. 
 
You asked the Plan to pay for the duplex scan of lower extremity arteries. You say that the services should be 
covered under the new State Balance Billing Protection Law. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the duplex scan of lower 
extremity arteries provided on September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), diagnostic radiology procedures of the head and neck (CPT 70310), a chest x-ray (CPT 71045) a 
swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) provided on 
October 14, 2022. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic 
radiology procedures of the head and neck (CPT 70310), a chest x-ray (CPT 71045) a swallowing function x-
ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240). You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were performed at a nursing 
home (via mobile van/portable x-ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. The file shows that these services were performed at a nursing home 
(via mobile van/portable x-ray) which is an excluded place of service per the Medicare LCD coverage criteria. 
Based on this information, we decided that Medicare rules for coverage of a neck/spine x-ray (CPT 72040), an 
x-ray of jaw (CPT 70100), diagnostic radiology procedures of the head and neck (CPT 70310), a chest x-ray 
(CPT 71045) a swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) 
have not been met. Therefore, we decided that the Plan does not have to pay for a neck/spine x-ray 
(CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of the head and neck (CPT 
70310), a chest x-ray (CPT 71045) a swallowing function x-ray (CPT 74230), and an upper gastrointestinal 
tract x-ray (CPT 74240) provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that your crown fell off. You had it rebonded 
but that only lasted a week. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 24, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that a SNF admission is 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has ongoing skilled therapy and nursing needs. Daily skilled services on 
an inpatient basis in a SNF is medically appropriate. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 procedure code(s) 88305-59, 88307, 88331, 88342, and 
88341 billed for date of service May 4, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305-59, 88307, 88331, 88342, and 88341. You say that you 
have provided documentation that should allow the claim to be paid. The Plan denied your request. The Plan 
says these codes are included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305-59, 88307, 
88331, 88342, and 88341. This means there is both a professional and technical component for the CPT 
code(s). In this case, an appropriate modifier to indicate the professional component has not been billed with 
CPT code(s) 88305-59, 88307, 88331, 88342, and 88341. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88305-59, 88307, 88331, 88342, and 88341 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code(s) 88305-59, 88307, 88331, 88342, and 
88341 billed for date of service May 4, 2022.