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

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on November 5, 2021. 
 
You asked the Plan to pay for a TENS device. You say that the item at issue is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for TENS therapy have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for CLBP will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The available medical documentation indicates that a TENS device 
has been requested for treatment of back pain. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pay for a 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. 
 
 
 
  Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on September 22, 
2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. 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 payable. 
 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. 
 
Review of the file shows that there are no progress notes/office notes provided to show why the enrollee 
needed to have this genetic testing done. Without this documentation, the cardiovascular genetic testing at issue 
in this appeal 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 cardiovascular genetic 
testing provided on September 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance transportation (A0427, A0425) 
provided on January 16, 2022. 
 
You asked the Plan to pay for emergency ambulance transport. You say that these services were medically 
necessary. The Plan denied your request. The Plan says there was a closer medical facility which would have 
been able to provide the necessary medical care. Transportation back to the United States was not necessary 
and is not a covered benefit regardless of circumstance. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the country, emergency services, including emergency or urgently needed care and emergency ambulance transportation from the scene of an emergency to the nearest medical treatment facility are covered 
services. Transportation back to the United States from another country is not covered. 
 
We looked at the file and Medicare rules. The documentation provided indicates that the enrollee experienced a 
medical emergency in Barbados while on a cruise and was transported back to the United States for emergency 
treatment. While the cruise ship may not have been able to provide sufficient medically necessary treatment, 
there was another facility which was closer to the enrollee and could have provided the necessary care. In 
addition, transportation back to the United States is not covered under any circumstance. Based on this 
information, we decided that the rules for coverage of emergency ambulance transport have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency ambulance transportation (A0427, 
A0425) provided on January 16, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on April 12, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry 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. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
reimbursed when billed for specimen validity testing on specimens used for drug testing. Furthermore, this 
code represents a not elsewhere specified code. However, a complete description of the not elsewhere specified 
code was not included. The order/ lab requisition must include what laboratory test was ordered/requested in 
order to validate the not elsewhere specified code billed. Therefore, the billed code and appended modifier 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the mass 
spectrometry and tandem mass spectrometry services have not been met. Therefore, we decided that the Plan 
does not have to pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided 
on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 vaccine provided October 11, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that this service was medically necessary and 
should be covered. The Plan denied your request. The Plan says original Medicare is liable for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare payment for COVID vaccinations 
administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS 
program. 
 
We looked at the file and Medicare rules. This service is covered by original Medicare. The claim must be 
billed to Original Medicare for payment. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 vaccine have not been met. Therefore, we decided that the Plan does not have to 
pay for a COVID-19 vaccine provided October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded 81406 and 81407 provided on 
September 16, 2021. 
 
You asked the Plan to pay for the laboratory testing. 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 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 codes 81406 and 81407 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 submitted for the panel in this case. Based on this 
information, we decided that Medicare rules for coverage of the laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81406 and 81407 
provided on September 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl Dis 50mcg/Hr. 
 
You asked the Plan to pre-approve the Fentanyl patch. You say that the enrollee has been taking this 
medication for several years, and sudden stop in using this medication could result in withdraw symptoms. The 
Plan denied your request. The Plan says Fentanyl 50mcg/hr patch is a self-administered drug and does not fall 
under Part B coverage. 
 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 Fentanyl Dis 50mcg/Hr.  
 
Benefits for the Fentanyl patch 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (01810) provided December 16, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary and 
pre-authorized. The services should be covered. The Plan denied your request. The Plan says that rules for 
coverage were not 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 did not clearly articulate why the claim was denied. The plan did not 
cite the applicable rules or regulations used to support the denial. Therefore, we decided that the Plan has to 
pay for the anesthesia services (01810) provided December 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ADmark Alzheimer's Disease lab test (coded as 
83520) immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, 
not otherwise specified. 
 
You asked the Plan to pre-approve the ADmark Alzheimer's Disease lab test. You say that the requested testing 
is medically necessary. The Plan denied your request. The Plan says the requested testing 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 the ADmark Alzheimer's Disease lab 
test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee is suspected of possibly having Alzheimer's Disease. 
CSF testing has been ordered as part of the evaluation. However, the requested testing has not readily been 
demonstrated to be beneficial in the formal evaluation of AD. It has not been shown to lead to a diagnosis in 
and of itself. Nor has it been demonstrated to be beneficial outside of the research setting. Rather further study 
is needed to determine what if any role such testing would have in clinical practice. In such a context, services would be best defined as being experimental. 
 
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 ADmark Alzheimer's Disease lab test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the ADmark Alzheimer's Disease lab test (coded as 83520) 
immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not 
otherwise specified.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance imaging (MRI) of any upper extremity joint, with 
contrast materials (73222, A9579) provided on May 20, 2021. 
 
You asked the Plan to pay for the MRI with contrast. You say that these services were pre-approved by the 
Plan based on medical necessity. The Plan denied your request. The Plan says that medical records were not 
provided to show the medical necessity of these services and these services were not pre-approved. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the MRI with contrast. The file includes a copy of a notice of pre-approval for 
this service to be performed by this provider for this enrollee from May 18, 2021, until November 14, 2021. 
Under Medicare rules, this means the MRI with contrast is considered approved by the plan. Therefore, we 
decided that the Plan has to pay for magnetic resonance imaging (MRI) of any upper extremity joint, with 
contrast materials (73222, A9579) provided on May 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the notes show the enrollee cannot tolerate an intensive therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight in an IRF. While the 
enrollee may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services provided on August 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the duration of 
time spent was not documented. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge services provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair itself and the other requested 
items/accessories to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have an amputated leg and 
need a power wheelchair as soon as possible. The Plan denied your request. The Plan says medically necessary 
care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the power wheelchair itself and the other requested items/accessories to be provided by an out-of-network 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 18, 2021, 
through September 28, 2021. 
 
You asked the Plan to pay for home health services. You say that the claim has the correct bill type. The Plan 
denied your request. The Plan says the claim was billed with an invalid type of bill and missing G and Q codes. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was not billed with the correct codes for home health services. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from August 18, 2021, through September 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to from January 10, 2022, 
through January 21, 2022. 
 
You asked the Plan to pay for home health services. You say that the claim has the correct bill type. The Plan 
denied your request. The Plan says the claim was billed with an invalid type of bill. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was submitted with an invalid type of bill. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to from January 10, 2022, through January 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services rendered on December 1, 
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 procedure code 97530 is not supported. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.  
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on 
December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing provided on December 
12, 2021. 
 
You asked the Plan to pay for the next generation sequence testing. 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 panels of tests that include the FANCC gene are 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
rendered included testing for the FANCC gene. This means the entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the next generation sequence testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the next generation sequence testing provided 
on December 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services rendered on January 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 that the services were not authorized. 
 
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 states that the services were not authorized; however, the enrollee has a 
PPO plan and can be seen by out-of-network providers. The Plan has not provided any further explanation, 
documentation, or Medicare rules to support that the services are not covered. Therefore, we decided that the 
Plan has to pay for the surgical services rendered on January 10, 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.