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

 
We decided that the Plan does not have to pay for the pneumatic compression device and related services 
provided on November 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the device is a proven treatment for deep 
venous thrombosis. The Plan denied your request. The Plan says the service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file, and Medicare rules. Items that are used for a preventative service or function are 
excluded from coverage. 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 
pneumatic compression device and related services provided on November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for surgical services. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 surgical services provided on January 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on February 16, 2022 by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay for the eyewear. You say that you contacted the treating provider and were told they 
accept your insurance. You also say that the provider's office contacted the insurance company for approval 
and you were told everything was covered. The Plan denied your request. The Plan says you must receive care 
from a network provider, and the treating provider is OON with your plan. The Plan also says that the 
insurance company does not show a call history of being contacted by you or the provider. 
 
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 these services when they are rendered by an approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that you received this eyewear from a non-
contracted provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on 
February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider from 
November 2, 2021, to December 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider from 
November 2, 2021, to December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine, 
without contrast (72148). 
 
You asked the Plan to pre-approve this service. You say that an MRI of the lumbar spine is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that an 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that there is no 
documentation of abnormal physical exam findings. You have not seen the enrollee back to follow up on 
conservative management. There is no specific clinical rationale for the requested MRI. The review has 
determined that the requested MRI of the lumbar spine, without contrast material is not medically necessary or 
reasonable. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine, without contrast (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on February 9, 
2022. 
 
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 this code is not recommended for separate reimbursement. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services provided to the enrollee on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 9, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on February 9, 2022 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee meets the criteria based on the 
related diagnosis. The Plan denied your request. The Plan says the testing is non-covered service. 
 
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 81291 is MTHFR (5,10-methylenetetrahydrofolate 
reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C). We find that CPT code 81291 was billed with a GZ modifier. Claim lines submitted with a GZ modifier shall 
be denied automatically. 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 the lab services provided on 
September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methylenetetrahydrofolate reductase (MTHFR) testing 
coded 81291 and unlisted molecular pathology procedure coded 81479 provided on November 21, 2021. 
 
You asked the Plan to pay for the MTHFR testing coded 81291 and unlisted molecular pathology procedure. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that testing for the 
MTHFR gene is only covered for enrollees who are pregnant. 
 Review of the file does not support that the enrollee was pregnant. This means the testing for the MTHFR gene 
is non-covered.  
 
We find that CPT code 81479 is not supported in the medical record. Specifically, this code was billed with the 
GZ modifier. Clarification of the claim was not obtained, despite various attempts from the Plan. Based on this 
information, we decided that Medicare rules for coverage of the MTHFR testing coded 81291 and unlisted 
molecular pathology procedure have not been met. Therefore, we decided that the Plan does not have to pay for 
the methylenetetrahydrofolate reductase (MTHFR) testing coded 81291 and unlisted molecular pathology 
procedure coded 81479 provided on November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on February 3, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics 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 records do not clearly document that 
the test was required to define the safe use of a specific drug in the enrollee. Records indicate the GeneSight 
testing was ordered at the request of the enrollee and no other rationale was provided. The criteria for coverage 
are not met and the testing was 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 GeneSight testing rendered on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full coverage of your fitness membership cost. 
 
You asked the Plan to pre-approve this service. You say that your orthopedic physician suggested this service 
as it would be helpful for preventive reasons to avoid spinal surgery. The Plan denied your request. The Plan 
says your request for full coverage, beyond the allowable benefit of $250, for your fitness membership has 
been denied. 
 
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 Plan covers gym benefits 
at an amount of $250. 
 
The Plans rules for coverage of gym benefits have not been met because your request is beyond the allowable 
benefit limit of $250. Therefore, we decided that the Plan does not have to pre-approve full coverage of your 
fitness membership cost.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the knee orthosis. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered for enrollees who have had 
a recent knee injury or surgery, or who have documented instability or laxity of the knee. 
 
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 knee orthosis. Our reviewer says 
that the orthosis is not medically necessary. Our physician reviewer found the records do not document recent 
injury to or a surgical procedure on the knee or objective description of joint laxity. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1852).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that an ILR 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found while you have a history of irregular 
rapid heartbeat (atrial fibrillation) and stroke for which anticoagulation is being used, ther is no documentation 
to show you have unexplained loss of consciousness due to low blood pressure (syncope) or any other 
indication for an ILR. The services are 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 pre-approve an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897) every 6 months. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. You also say 
that you cannot take Fosamax due to your esophagus irritation. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drug, zoledronic acid. 
 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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The reviewer found that 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. Therefore, the reviewer found that 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897) every 6 months.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom prosthetic protective distal finger cap needed for 
left hand (CPT code L7499). 
 
You asked the Plan to pre-approve the prosthetic. You say that you need this prosthetic so you can prevent 
reinjury to your finger. You state this prosthetic is constructed so you will not be injured again in the future. 
You state that right now you do not have anything, and you are afraid you will be hurt again because your 
fingertip was amputated. The Plan denied your request. The Plan says the requested prostheses are not 
reasonable and necessary per Medicare criteria. The Plan states the requested prostheses cannot be covered as 
the incorrect code is used. 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 prosthetic have not been met. 
The code used does not match the item requested. This cannot be covered as requested. The requested device 
exceeds your needs and cannot be covered. Therefore, we decided that the Plan does not have to pre-approve 
custom prosthetic protective distal finger cap needed for left hand (CPT code L7499).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (70544-59) provided on January 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that modifier -59 is not 
supported by the records provided. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services Our reviewer says that the use 
of modifier -59 is supported by the records provided. Our physician reviewer found that the documentation 
describes a complete MRI head (images of organs and tissues), as well as complete MRA brain (blood vessels). 
In this case, modifier -59 is supported by medical record. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (70544-59) provided on January 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction (S0620), deluxe eyeglass frames (V2025), progressive lens (V2781), and anti-reflective coating 
(V2750) provided on January 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine examination, deluxe eyeglass frames, progressive lens, and anti-
reflective coating. You say that this provider has been your optician and eyeglass provider for the past 20 years. 
You also say that the optometrist with this company has your previous eye health history and eyeglass 
prescriptions. The Plan denied your request. The Plan says the treating provider is OON, and you do not have 
benefits for OON doctors on your plan. The Plan also says that this claim has processed correctly, and you are 
responsible for the services you received. 
 
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 these services when they are provided by an approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that you received this eyewear from a non-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the routine examination, 
deluxe eyeglass frames, progressive lens, and anti-reflective coating have not been met. Therefore, we decided 
that the Plan does not have to pay for the routine ophthalmological examination including refraction (S0620), 
deluxe eyeglass frames (V2025), progressive lens (V2781), and anti-reflective coating (V2750) provided on 
January 5, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that the 
elements of coverage for Feraheme have been satisfied. Our physician reviewer found the provided 
documentation indicates that the enrollee has not had a satisfactory response to oral iron supplementation or 
Venofer. The reviewer found that the Food and Drug Administration (FDA) has stated that the requested drug 
is indicated for the enrollee's condition.   Therefore, the reviewer found that the elements of the coverage 
criteria are 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 Feraheme have been met. Therefore, we decided that the Plan has to pre-
approve Feraheme (Q0138).  
 
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.