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

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on October 19, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 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 the abdominal ultrasound (76705) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a transcutaneous electrical nerve stimulation (TENS) device. 
 
You asked the Plan to pre-approve a TENS device. You say that you have been in pain for years and you had 
this device with your other insurance, but it doesn't work anymore. You say that you have had therapy and 
acupuncture but that the pain isn't relieved. You say that the pain is from your neck all the way down, and that 
your nerves are very bad. The Plan denied your request. The Plan says that the medical notes do not indicate 
that the enrollee has the required conditions for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that TENS therapy is covered for chronic pain when 
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 a TENS device. Our reviewer says that 
the requested TENS device is medically necessary and the criteria for coverage have been met. Our physician 
reviewer found the enrollee has chronic pain from hereditary motor and sensory neuropathy. The enrollee has 
loss of sensation in her legs/feet. She takes Gabapentin, Baclofen and Voltaren for pain. She has previously 
used a TENS unit with success. She has tried acupuncture without benefit. 
 
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 TENS device have been met. Therefore, we decided that the Plan has to pre-
approve a transcutaneous electrical nerve stimulation (TENS) device.  
 
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 the pharmacogenomics gene panel provided on September 3, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the results will allow for the most effective 
treatment decisions. The Plan denied your request. The Plan says only a single code shall be reported for the 
procedure. 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 looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure. 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 pharmacogenomics gene panel provided on 
September 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Capecitabine and Herceptin for the enrollee.
You asked the Plan to pre-approve Capecitabine and Herceptin. You say that this drug treatment is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the
correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Capecitabine.
Our Physician Reviewer determined that Capecitabine is medically reasonable and necessary in this
case. While the requested drug is not FDA-approved for the enrollee's condition, the use of the requested drug
is supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved
medical journal. It was determined that the documentation supports that the requested drug is safe and effective
and otherwise reasonable and necessary for this enrollee.
The Plan requested a reopen and argues that the request was for combination therapy of Capecitabine with
Herceptin (Trastuzumab).
The medical records show the enrollee is a 69-year-old woman with HER2 positive adenocarcinoma of the
gallbladder. A positron emission tomography scan showed significant worsening with local recurrence with
liver and peritoneal metastases. The treatment plan was for Herceptin and Capecitabine. Our Medical Director
has concluded that the Plan is correct in this case. There is insufficient support for the use of Herceptin and
Capecitabine for the treatment of metastatic adenocarcinoma of the gallbladder.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Capecitabine have not been met. Therefore, we decided that the Plan does not
have to pre-approve Capecitabine and Herceptin for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided 
October 15, 2021 by an out of network provider. 
 
You asked the Plan to pay for the diagnostic services. You say that the enrollee meets all of the requirements 
for coverage of F1CDx under the NCD. The Plan denied your request. The Plan says procedure code 0037U 
was not billed as per CMS regulations. 
 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 0037U is FoundationOne CDx: Targeted genomic 
sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene 
copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the Plan was unable to 
verify physician order. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the targeted 
genomic sequence analysis (0037U) provided October 15, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive genomic profiling test provided on 
September 1, 2021. 
 
You asked the Plan to pre-approve the testing services. You say that the test is proven medically necessary. The 
Plan denied your request. The Plan says the test is non-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. The file shows that the gene panel at issue was billed with CPT code 
81455. Genetic testing procedures submitted under CPT code 81455 is unlikely to impact therapeutic decision-
making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the comprehensive genomic profiling test provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says Botox is never covered 
by Medicare for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.
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. 
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You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 17, 2021, to October 16, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not need daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from September 17, 2021, to October 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a volume management system (L5781), a shock 
reducing addition (L5988), and knee components (L5856, L5828, L5848, L5845, L5850). 
 You asked the Plan to pre-approve a volume management system, a shock reducing addition, and knee 
components. You say that these items are medically necessary. The Plan denied your request. The Plan says the 
requested components exceed your needs. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components are covered when medically 
necessary as defined in the 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 a volume management system, a shock 
reducing addition, and knee components. Our reviewer says that the requested items are not medically 
necessary. Our physician reviewer found the records within the past year from your treating provider do not 
document edema or volume fluctuation on examination to support the need for the requested volume 
management system (L5781). The records also do not document why the shock reducing addition (L5988) is 
necessary and the most appropriate equipment for the enrollee's condition. The records from the treating 
provider do not support you are a K3 level ambulator, meaning the requested knee components (L5856, L5828, 
L5848, L5845, L5850) are 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 a volume management system, a shock reducing addition, and knee components 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a volume management 
system (L5781), a shock reducing addition (L5988), and knee components (L5856, L5828, L5848, L5845, 
L5850).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5257, 99199) provided on April 
16, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that this cost is a financial hardship. The Plan denied 
your request. The Plan says these hearing aids were not purchased through the specified hearing vendor, and 
therefore are ineligible for payment. 
 
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. The Plan pays for 
hearing aids only when they are purchased through the specified routine hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from a provider other 
than the one specified by the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid 
services (V5257, 99199) provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth provider visit (99202) billed for date of service 
February 3, 2021. 
 
You asked the Plan to pay for a telehealth provider visit. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a telehealth provider visit (99202) 
billed for date of service February 3, 2021. have been met. Specifically, the provided medical records do not document the service billed. Therefore, we decided that the 
Plan does not have to pay for a telehealth provider visit (99202) billed for date of service February 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fluoroscopic guidance for needle 
placement (77002) provided on August 3, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility. 
 You have been asked to pay $108.91 for the Medicare-covered radiological diagnostic service provided. This is 
the Plans allowed amount for this service which is less than the applicable copayment. 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 the fluoroscopic guidance for needle placement (77002) provided on 
August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an inpatient hospital stay provided from May 19, 
2021, to May 21, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
out-of-pocket expense. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. The Plan also says that the claim was processed at the in-network rate. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that enrollees must pay a 
$0 copayment for an in-network inpatient hospital stay.  
 
The remittance advise shows the Plan agreed to cover the out-of-network stay at the in-network rate. The Plan 
says the enrollee must pay a $2,554 copayment for an inpatient hospital stay. Based on the plan contract, 
however, the enrollee cannot be asked to pay more than $0 copayment for an in-network inpatient hospital stay. 
Therefore, we decided that the Plan has to waive the copayment for an inpatient hospital stay provided from 
May 19, 2021, to May 21, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay (0089U) provided on October 7, 
2021. 
 
You asked the Plan to pay for the Pigmented Lesion Assay. You say that this test for melanoma was ordered by 
an in-network provider. You also say that your doctor informed you that this test was the easiest way to 
determine if surgery was necessary. The Plan denied your request. The Plan says no benefits are owed for this 
test because it 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 Pigmented Lesion Assay. Our reviewer 
says that the Pigmented Lesion Assay is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provider at the time the test was ordered did not document in the office visit 
record that she thought it was more likely to be melanoma or even reference the possibility that it could be 
melanoma. Our reviewer found that there was no photograph or measure of the lesion. Our physician reviewer 
also found that there was no documented plan to follow the lesion other than that the provider would call the 
enrollee with the results of the test. 
 
 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 Pigmented Lesion Assay have not been met. Therefore, we decided that the 
Plan does not have to pay for the Pigmented Lesion Assay (0089U) provided on October 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound guidance for vascular access (76937) provided on 
August 15, 2021. 
 
You asked the Plan to pay for ultrasound guidance for vascular access. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 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 76937 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for ultrasound guidance for vascular access (76937) provided on August 15, 2021.