Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the hearing aids (V5261 x 2) 
purchased on August 9, 2022. 
 
You asked the Plan to issue additional reimbursement for these items. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for these items. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of these items have not been met. Specifically, the Plans contract states that there is a 
$1,000 allowance provided for up to two hearing aids every two calendar years. The Plan issued payment to 
you on October 28, 2022 for the hearing aids purchased, in the amount of $1,000 after your appeal was filed. 
Therefore, you have exhausted the allowable benefit for these items. Therefore, we decided that the Plan does 
not have to issue additional reimbursement for the hearing aids (V5261 x 2) purchased on August 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the requested Remicade is medically necessary. 
The Plan denied your request. The Plan says the enrollee must try and fail Renflexis first. 
 
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 Remicade. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 15, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 85610, 85347, 80048 and 85027 billed for date of 
service March 23, 2022. 
 
You asked the Plan to pay for procedure codes 85610, 85347, 80048 and 85027. You say that these services 
were reported appropriately. The Plan denied your request. The Plan says that procedure codes 85610, 80048 
and 85027 are inconsistent with the modifiers used, and procedure code 85347 was billed with more units than 
are allowed by Medicare. 
 
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 original claim as submitted by the provider was not included in 
this case file. Without the original claim, we cannot verify whether any modifiers were or were not used 
appropriately, nor can we verify the number of units billed for any service. Therefore, we decided that the Plan 
has to pay for procedure codes 85610, 85347, 80048 and 85027 billed for date of service March 23, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there was no documentation to support that the enrollee 
is taking calcium supplements. The Plan also says that the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that when using denosumab (Prolia), it is required the 
patient adequately supplemented with calcium and vitamin D (calcium 1000 mg daily and at least 400 IU 
vitamin D daily). 
 
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 
requested drug, Prolia, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has stated that the requested drug is indicated for the enrollee's condition. The reviewer found 
that the provided documentation does not indicate calcium supplementation, a requirement under the local 
coverage article. Therefore, the reviewer found that the requested drug is not 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a a pneumatic compression device (PCD) (E0651) and 
bilateral leg sleeves (E0667) . 
 
You asked the Plan to pre-approve a PCD and bilateral leg sleeves. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the documents show an improvement in the 
lymphedema with conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD is covered when all the criteria listed in the 
Medicare Rules section 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 PCD and bilateral leg sleeves. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the documents show an 
improvement in the lymphedema with conservative treatment. 
 
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 PCD and bilateral leg sleeves have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a a pneumatic compression device (PCD) (E0651) and bilateral leg 
sleeves (E0667) .
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. The Plan denied your request. The Plan says this 
request is not medically necessary because the records show that the guidelines for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
transmitter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computerized tomography (CT) scan on December 2, 2021. 
 
You asked the Plan to pay for a computerized tomography (CT) scan. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services requested are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for a computerized tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the review of the 
submitted material revealed no medical records nor report from the CT of the chest.  Absent any medical 
records or reports the medical necessity of the performed CT of the chest cannot be determined. 
 
 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 computerized tomography (CT) scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a computerized tomography (CT) scan on December 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin U-500 injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not being used for an insulin pump and is going to be self-
administered. 
 
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 Humulin U-500 injection.   
Benefits for the medication 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 procedure code 76705 billed for date of service September 
15, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service September 15, 
2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on August 19, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says that Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee -
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 has not provided us with proof of hospice enrollment. 
Therefore, we decided that the Plan has to pay for laboratory services provided on August 19, 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: Unfavorable

 
We decided that the Plan does not have to pay for the nerve block (64999) provided on March 3, 2022. 
 
You asked the Plan to pay for the nerve block. You say that you had knee replacement surgery. You say that 
you needed the nerve block for your pain. You also say that you returned home the same day as the surgery. 
The Plan denied your request. The Plan says the service in this case was 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 pay for the nerve block. Our reviewer says that the 
nerve block is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation does not include a separate post-op pain consult by the surgeon documented. 
Therefore, the reviewer found that there is insufficient documentation to support the medical necessity of the 
nerve block. 
 
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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pay for the nerve block (64999) provided on March 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 7, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says you billed 
with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, this claim was billed with the hospice POS 
code. The records do not support that the enrollee was under the hospice benefit when the services were 
provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
August 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil. 
 
You asked the Plan to pre-approve Sildenafil. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Sildenafil.  
 Benefits for Sildenafil 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen. 
 
You asked the Plan to pre-approve oxygen. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested oxygen is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen Our reviewer says that the 
requested oxygen is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
diagnoses of heart failure, chronic obstructive pulmonary disease and pulmonary hypertension. The 
documentation does not document hypoxia and do not contain the required information for coverage. 
The clinical evidence that leads this reviewer to conclude that despite a level of oxygen saturation greater than 
89%, supplemental oxygen is still medically necessary and 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 oxygen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve oxygen.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomograph (SPECT) scan 
(78452). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says that this request 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a SPECT scan is useful in the diagnosis of several 
clinical 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 a SPECT scan. Our physician reviewer 
found while the enrollee has no symptoms of angina, they do have an abnormal electrocardiogram with right 
bundle branch block and left axis deviation. Our reviewer found that the enrollee's echocardiogram revealed 
left ventricular hypertrophy and they have an elevated cholesterol. Our physician reviewer also found that the 
combination of all these factors provide enough of an indication for the requested Lexiscan stress test with 
SPECT. 
 
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 SPECT scan have been met. Therefore, we decided that the Plan has to pre-
approve a single photon emission computed tomograph (SPECT) scan (78452).  
 
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 86077 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 9, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 86077 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 86077 billed for date of service 
August 16, 2022.