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

 
We decided that the Plan does not have to pay for the respiratory assist device provided on March 7, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 the respiratory assist device provided on March 7, 
2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an MRI of the brain . We decided that the Plan does not have to 
pre-approve a CT scan of the pelvis.  
 
We decided that the Plan has to pre-approve an MRI of the brain. You asked the Plan to pre-approve an 
MRI of the brain. You say that the MRI is medically necessary. The Plan says that the MRI is not reasonable 
and necessary.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the brain. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the request for MRI of the brain to 
evaluate for metastatic disease in a patient with uveal melanoma and known metastases to the brain is 
reasonable and necessary. Therefore, we decided that the Plan has to pre-approve an MRI of the brain .  
 
We also decided that the Plan does not have to pre-approve a CT scan of the pelvis. You say that the CT 
scan is medically necessary. The Plan says that the CT scan is not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the pelvis. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the notes indicate a CT scan of 
the chest and pelvis was done at an outside facility. No formal report is included but the notes say no metastatic 
disease was seen in the pelvis. The medical necessity of a repeat CT of the pelvis 5 weeks later has not been 
clarified. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the pelvis. 
 
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 laboratory services related to end-stage renal disease 
(ESRD) provided on February 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on March 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that the enrollee had been injured or directly exposed to any illness related to these 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on March 
16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation device. 
 
You asked the Plan to pre-approve an Aurora Spine ZIP Interspinous Fixation device. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 an Aurora Spine ZIP Interspinous 
Fixation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the Zip interspinous process fusion device is 
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 an Aurora Spine ZIP Interspinous Fixation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation 
device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on February 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 21 for 
inpatient but the enrollee was not under inpatient status at the date of service. Therefore, we decided that the 
Plan does not have to pay for the initial hospital care rendered on February 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 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 November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for genetic testing provided on March 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC and BLM genetic testing rendered on June 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not covered. 
 
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. the Plan references Local Coverage Article (LCA) A55183 and A55113 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC and BLM genetic testing rendered on June 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound covers and dressing supplies provided on February 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound covers and dressing supplies. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound covers and dressing supplies provided on 
February 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
March 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more classes provided on 
February 15, 2022, billed with code G0483. 
 
You asked the Plan to pay for the definitive drug panel as billed. You say that the records support that this 
testing was medically necessary. The Plan denied your request. The Plan says the documentation does not 
support the number of drug classes reported. 
 
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 the definitive drug testing of 22 or 
more classes have been met. The file did not contain a copy of the lab report showing the results of the testing 
performed. The only record was a note indicating the medical necessity of the additional drug classes. Without 
the results of the lab testing, the billed code is not supported. Therefore, we decided that the Plan does not have 
to pay for the definitive drug testing of 22 or more classes provided on February 15, 2022, billed with code 
G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vest Airway Clearance System. 
 
You asked the Plan to pre-approve the Vest Airway Clearance System. 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 follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 Vest Airway Clearance System. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the Vest Airway Clearance System at issue in this case meets 
Medicare criteria for medically reasonable and necessary. Provided records do not document a confirmed 
diagnosis of bronchiectasis, a neuromuscular disease or cystic fibrosis as required by the Local Coverage 
Determination (LCD): High Frequency Chest Wall Oscillation Devices - L33785. 
 
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 Vest Airway Clearance System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vest Airway Clearance System.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a concentric adjustable torsion style mechanism for use with an 
approved custom knee brace. 
 
You asked the Plan to pre-approve the concentric adjustable torsion style mechanism. You say that the enrollee 
requires both the brace and the additional custom component. The Plan denied your request. The Plan says that 
code L2861 is not a valid code and cannot be used with the requested brace. Therefore, the Plan is not required 
to approve coverage for the item. 
 
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. The Plan has not provided a valid rationale for the requested item. The Plan has 
denied the request based on a coding argument. The Plan indicates that because the code that the provider 
requested is not valid for Medicare, the Plan does not have to approve the item being requested. We note that 
coding arguments are only appropriate when a billed claim exists. This is to ensure that access to medically 
necessary and covered items/services is not impeded by a provider simply requesting an incorrect code for an 
item that is otherwise covered. The Plan has not provided any evidence to support that the requested addition to 
the knee brace is not covered by Medicare, nor that it is not medically necessary. The Plan must provide 
coverage for the item itself and can work with the supplier to determine the appropriate code for the requested 
item. Therefore, we decided that the Plan has to pre-approve a concentric adjustable torsion style mechanism 
for use with an approved custom knee brace.  
 
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 eye refraction services provided on January 21, 2022. 
 
You asked the Plan to pay for the eye refraction services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says you were seen for a medical condition. 
Routine eye exams for medical conditions are not covered by Medicare or the Plan.  
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 once per year for people without known eye conditions or symptoms. 
 
We looked at the file and the Plan's rules.  The file shows that you received this eye exam for a medical 
condition. Based on this information, we decided that the Plan's rules for coverage of the eye refraction services 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services 
provided on January 21, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is a clear lack of 
documentation of the percentage pain relief achieved after each diagnostic set of medial branch blocks (MBBs) 
and you underwent radiofrequency ablation (RFA) of levels that were not blocked diagnostically. The request 
is considered 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service September 
16, 2021. 
 
You asked the Plan to pay for procedure code 88341. You say that you have provided medical records to 
support the service at issue. The Plan denied your request. The Plan says payment for code 88341 is bundled 
into payment for code 88360. 
 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 88341 
is a column II code to column I code 88360. 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 88341 billed for date of service September 16, 
2021.