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

 
We decided that the Plan does not have to pay for procedure codes 88341-26 and 88342-26 billed for date of 
service May 23, 2022. 
 
You asked the Plan to pay for procedure codes 88341-26 and 88342-26. You say that the patient had multiple 
exams on this date of service. The Plan denied your request. The Plan says payment for codes 88341-26 and 
88342-26 is bundled into payment for code 88360-26. 
 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 codes 
88341-26 and 88342-26 are column II codes to column I code 88360-26. 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 codes 88341-26 and 88342-26 
billed for date of service May 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart without 
contrast for quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says imaging to measure the amount of calcium deposits in the blood vessels that supply 
blood to your heart muscle (quantitative calcium scoring) is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
Medicare does not consider this type of computed tomography (CT) scan with calcium scoring to be medically 
reasonable or necessary at this time. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve computed 
tomography (CT) scan of the heart without contrast for quantitative evaluation of coronary calcium.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on July 6, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and was reported correctly. 
The Plan denied your request. The Plan says that the record only supports the testing of 11 drug classes; 
therefore, this service is not supported 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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers, 15-21 drug class(es), including metabolite(s), if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that 
between 15 and 21 drug classes were tested in this panel, including alcohol biomarkers, amphetamines, 
antidepressants (serotonergic class), antidepressants (not otherwise specified), benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin and 
skeletal muscle relaxants. Based on this information, we decided that Medicare rules for coverage of drug 
testing have been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0482) 
provided on July 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on June 03, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $49 
copayment for Services received from all other specialists.. 
 
You have been asked to pay a $49 copayment for telehealth visit. This item/service falls within the Services 
received from all other specialists. benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
telehealth visit provided on June 03, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening. 
 
You asked the Plan to pre-approve an LDCT scan for lung cancer screening. You say that your first computed 
tomography (CT) scan showed 1 nodule, and the second scan showed two nodules. You also say that you feel 
this service is medically necessary because its purpose is to monitor the enlargement and progression of the 
nodules. The Plan denied your request. The Plan says that the provider requested the incorrect type of CT scan, 
and any more details are unable to be verified with the limited information provided. 
 
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. Medical records, including results from previous scans, were not provided with 
this case. We asked for this documentation, but it was not provided to us. Without this information, we cannot 
determine if the requested LDCT scan is not medically necessary. Consequently, the Plan has not substantiated 
their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is considered experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopy services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve endoscopy services. You say that the provider is trying to do a procedure 
with a machine only available at another facility. You also say you do not want to change specialists. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 
endoscopy services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 76641-LT-RT billed for date of service June 1, 2022. 
 
You asked the Plan to pay for code 76641-LT-RT. You say that the patient had multiple exams on this date of 
service. 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 July 22, 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 code 76641-LT-RT have not been met. Therefore, 
we decided that the Plan does not have to pay for code 76641-LT-RT billed for date of service June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 22, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says utilization of 
network providers and authorization for certain services are required. 
 
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 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 lab services provided on December 22, 2020, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collapsible walker with wheels and equipment for a health 
condition provided on March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment (DME). You say that you could not find the specific 
walker that was recommended to you in your location. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advanced. 
 
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 collapsible walker with wheels and equipment for 
a health condition provided on March 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation, initial 15 minutes, (99152) provided 
on February 24, 2022. 
 
You asked the Plan to pay for the sedation service. You say that the service should be covered. The Plan denied 
your request. The Plan says the submitted procedure code is not supported by the provided documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the record shows that the enrollee received 73 minutes of sedation. Based on this information, we decided that Medicare rules for 
coverage of the sedation service have not been met. Therefore, we decided that the Plan does not have to pay 
for the moderate sedation, initial 15 minutes, (99152) provided on February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up for CPAP machine(A9270). 
 
You asked the Plan to pre-approve a battery back-up. You say that you are appealing the denial of the battery 
backup for your CPAP machine. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. External batteries 
or any alternate power source (example: generators) are not considered medical equipment by Medicare. This 
item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve a battery back-up for CPAP machine(A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 clinical documentation shows that the enrollee has functional impairments however there are no complex functional deficits listed, thus they would not be expected to require intense 
therapy or interdisciplinary rehabilitation management in an IRF setting. Additionally, there are no active 
comorbidities listed thus the enrollee would not require hospitalization for close medical monitoring in an IRF. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay $110 copayment for ultrasound. This item/service falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for ultrasound provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine exam, frames, and bifocal lens provided by an 
out-of-network provider on June 17, 2022. 
 You asked the Plan to pay for the routine exam, frames, and bifocal lens. You say that you hoped to recover the 
$50 that the Plan pays on routine eye exams. The Plan denied your request. The Plan says the services are not 
covered when obtained from an out-of-network 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 services are received by a provider in the Plan's vision vendor 
network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the routine exam, frames, and bifocal lens have 
not been met. Therefore, we decided that the Plan does not have to pay for the routine exam, frames, and 
bifocal lens provided by an out-of-network provider on June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 wound care supplies provided on February 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InSpace balloon device for shoulder arthroscopy. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary, as the enrollee has 
undergone therapy for several months without improvement. The Plan denied your request. The Plan says this 
should only be used in the context of research at this time. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. Regardless the requested 
InSpace has not been proven for safety/efficacy in published, large-scale, long-term peer-reviewed literature. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the requested InSpace balloon device for shoulder 
arthroscopy, in this case, is not medically reasonable or necessary.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an InSpace balloon device for shoulder arthroscopy.