Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive electrophysiologic evaluation (93621) 
and cardioversion (92960) provided on October 20, 2020. 
 
You asked the Plan to pay for the comprehensive electrophysiologic evaluation (93621) and cardioversion 
(92960). You say that medical records have been sent multiple times along with the claim. You say that the 
records should be reviewed, and the claim reprocessed. The Plan denied your request. The Plan says the claim 
was not billed with a modifier to bypass the code edit. 
 
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 93621 
and 92960 are column II codes to column I code 93656. CPT code 93621 has a modifier indicator of 0. This 
column II code is therefore not payable. CPT code 92960 has a modifier indicator of 1. This code 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 comprehensive 
electrophysiologic evaluation (93621) and cardioversion (92960) provided on October 20, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent antigen detection by immunoassay 
technique (87426) provided on November 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the infectious agent antigen detection. You say that you were unaware that you 
needed to get a referral from your provider. You also say that you thought you could go get a test if you were 
exposed. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 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 the infectious agent antigen detection by 
immunoassay technique (87426) provided on November 23, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from January 3, 2022, to January 4, 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 there were no skilled therapy or skilled nursing needs. 
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based 
on the medical records provided, there is no documentation that the patient required skilled nursing or skilled 
therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified 
therapist were not required to safely and effectively provide medically necessary and reasonable treatment from 
January 3, 2022 to January 4, 2022. The records did not document the need for intravenous medications, new 
tube feeding or ostomy care or daily complex wound care. Daily skilled services were not required. The patient 
was repeatedly refusing to participate and was discharged from skilled therapy services. The enrollee did not 
require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the nursing 
facility appear custodial in this case from January 3, 2022 to January 4, 2022. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from January 3, 2022, to January 
4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cataract surgery. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the facility where the surgery is to be performed is 
OON. 
 
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 only willing to perform this surgery at a facility that is not a network 
provider with the Plan. The Plan has network providers that will use network facilities 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 cataract surgery 
to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenomics panel provided on 
April 13, 2021. 
 
You asked the Plan to pay for the comprehensive pharmacogenomics panel. You say that this was medically 
necessary testing and was correctly billed. The Plan denied your request. The Plan says the reported POS code 
does not match the location in which the sample was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 comprehensive pharmacogenomics panel 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 the comprehensive pharmacogenomics panel 
provided on April 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan 
requires a trial of Renflexis, Inflectra, or Avsola before it will approve Remicade. 
 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 
enrollee does not meet the Medicare criteria for a step therapy exception for Remicade. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Renflexis, Inflectra, or Avsola. The 
record does not show that these drugs would likely be less effective and/or 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 use of Remicade.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice care provided on November 4 to November 11, 
2020. 
 
You asked the Plan to pay for hospice care. You say that the hospice care at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 3, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospice care 
provided on November 4 to November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) removals of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that you have upper dentures and do 
not have teeth below. Your daughter grinds up your food so you can eat and not injure your gums which can 
cause bleeding if you chew something hard. You also say you are losing weight since you are unable to eat 
properly. The Plan denied your request. The Plan says the requested service is not a covered benefit with your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
(2) removals of torus mandibularis (D7473).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January 
13, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed with an incorrect place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that 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 blood smear services have not been met. Specifically, this claim was billed with place of 
service 22 (On Campus-Outpatient Hospital). Code 85060 has a technical component/professional component 
indicator of 8. This value identifies the only payment made for the professional component of the code is for 
hospital inpatient. This means this code was billed with an incorrect place of service. 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 the blood smear services coded 85060 provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on 
February 8, 2021. 
 You asked the Plan to pay for genetic testing. You say that medical necessity has been signed off by the 
ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this testing is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
hereditary cardiovascular screening panel testing provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on November 4, 
2021 to November 12, 2021. 
 
You asked the Plan to pay for home infusion therapy. You say that the claim at issue requires reconsideration. 
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. 
 We find that CPT code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (S9500) provided on November 4, 2021 to November 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional levels for a laminectomy for the enrollee. 
 
You asked the Plan to pre-approve the additional levels. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation to support a plan for a laminectomy to three 
additional levels as requested. 
 
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 additional levels. Our reviewer says 
that the requested additional levels are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding the provider-designated plan for the 
additional three levels. The documentation does not indicate as to which levels are being requested. The lumbar 
magnetic resonance imaging (MRI) for 1/7/22 does not reasonably corroborate pathology at the (non-fully 
delineated) additional levels to support this procedure. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested three additional levels for the laminectomy, 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 additional levels have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional levels for a laminectomy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5299) provided on November 26, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for out-of-network hearing aids. You say that you dislike the Plan's hearing vendor 
because of how the providers have treated you in the past, and had a much better experience with the out-of-
network provider. The Plan denied your request. The Plan says out-of-network hearing services are not covered 
by your benefit. 
 
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 Plans specified routine hearing vendor network.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the specified vendor network. 
Based on this information, we decided that the Plan's rules for coverage of out-of-network hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5299) provided 
on November 26, 2021, by an out-of-network provider.  
 
Your complaint about the care received from the Plans contracted hearing vendor is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology, gross and microscopic examination 
(88305) provided on March 8, 2018 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that you are appealing the Plan's denial of 
payment. The provider sent an outpatient referral form to the Plan but it was refused because the Plan 
representative said no prior authorization was required. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 pathology, gross and microscopic 
examination (88305) provided on March 8, 2018 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator (SCS) services. 
 
You asked the Plan to pre-approve the SCS services. You say that the records provided support the need for the 
requested services. The Plan denied your request. The Plan says the records did not show that conservative 
treatments were tried and failed, and that the insertion of a stimulatory is only used as a late resort for patients 
with intractable pain. 
 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 SCS services. Our reviewer says 
that SCS services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has chronic low back and diabetic peripheral neuropathy. He takes Tramadol and Lyrica for 
pain. His nerve conduction velocity (NCV) also shows lumbar radiculopathy. He has psychological clearance 
for a SCS trial. He has no past history of spine surgery and no imaging is presented for review. He has not had 
physical therapy or a recent surgical consult. Our physician reviewer found that the enrollee does not have an 
evidence based indication for a SCS trial. 
 
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 SCS services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve spinal cord stimulator (SCS) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient surgery provided on 
December 3, 2021. 
 
You asked the Plan to waive the deductible for the outpatient surgery. You say that the cost share is wrong. The 
Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not 
been met at the time the outpatient surgery was received on December 3, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the outpatient surgery provided on December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued coverage for a portable ventilator (E0466) 
 
You asked the Plan to pre-approve continued coverage for a portable ventilator. You say that the requested 
device is medically necessary. The Plan denied your request. The Plan says that the requested device does not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 continued coverage for a portable 
ventilator. Our reviewer says that the service is medically necessary. Our physician reviewer found you have 
ALS, a progressive neurological disease leading to paralysis and chronic respiratory failure. Your vital capacity 
is 30% predicted, which is not sufficient to maintain adequate ventilation. Removal of the ventilator would 
quickly lead to serious consequences, including death. Battery backup is necessary. The capability for sip-and-
puff ventilation 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 continued coverage for a portable ventilator have been met. Therefore, we 
decided that the Plan has to pre-approve continued coverage for a portable ventilator (E0466)  
 
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.