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

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that this request is not covered. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. You were recently hospitalized for a 
COPD exacerbation requiring intubation. Venous blood gases suggest CO2 retention, but there is no arterial 
blood gas done while stable as an outpatient to confirm chronic CO2 retention. The average volume-assured 
pressure support mode that has been ordered can be provided via BiPAP, and there is no documentation of 
BiPAP failure at home, when stable.  Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide, hospital bed with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that due to the enrollee's weight, family members 
are having difficulty transporting the enrollee from room to room. You also say that you would like to request a 
hospital bed for the enrollee. The Plan denied your request. The Plan says the records do not show that the 
enrollee weighs more than 350 pounds, their current weight is 246 pounds. The Plan also says that this request 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
a heavy duty, extra wide, hospital bed with weight capacity greater than 350 pounds, but less than or equal to 
600 pounds is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
patients condition does not require positioning of the body, e.g., to alleviate pain, promote good body 
alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed. Our 
reviewer found that the patients condition does not require special attachments that cannot be fixed and used 
on an ordinary bed. Our physician reviewer also found that the heavy duty, extra wide bed exceeds the patient's 
needs as the patient's weight is not greater than 350 lbs.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heavy duty, extra wide, hospital bed with weight capacity greater than 350 pounds, 
but less than or equal to 600 pounds (E0303).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on September 
24, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the records support multiple procedures rendered. The 
Plan denied your request. The Plan says a modifier was not billed on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed on the same date of services as CPT code 70496. We find that 
CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does not 
show that the code at issue as billed with a modifier suitable for payment. Based on this information, we 
decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) scan provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2750) and three endodontic therapies 
(D3310 x3) provided on May 11, 2021, and May 26, 2021. 
 
You asked the Plan to pay more for the crown and endodontic therapies. You say that you would like to be 
refunded for these services. The Plan denied your request. The Plan says the total $972.50 amount applied 
correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and 
cannot be waived. 
 
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, you are responsible for a 50% 
coinsurance for each crown (D2750) and endodontic therapy (D3310). Therefore, we decided that the Plan does 
not have to pay more for the crown (D2750) and three endodontic therapies (D3310 x3) provided on May 11, 
2021, and May 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy sessions provided from July 12, 2021, 
through November 11, 2021 
 
You asked the Plan to pay for psychotherapy sessions. You say that the psychotherapy sessions are medically 
necessary. The Plan denied your request. The Plan says you are responsible for paying the full cost of services 
that arent covered by our plan, either because they are not plan covered services, or they were obtained  
out-of-network and were not authorized. 
 
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 
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 psychotherapy sessions provided from July 12, 2021, through 
November 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on October 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 20, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on October 12, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on October 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D biopsy (88312, 88361, 88104, 88305) provided 
June 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review and respond with coverage of 
your claim for the performance of WATs 3D tissue analysis. The Plan denied your request. The Plan says 
review of the medical literature and clinical practice guidelines does not support the clinical utility of this 
testing, including computer-assisted immunohistochemistry, to predict cancer. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for WATS 3D biopsy (88312, 88361, 88104, 88305) provided June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 20, 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 the services were not billed correctly. 
 
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 these 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 the drug testing rendered on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for hereditary thrombophilia (81240, 
81241). 
 
You asked the Plan to pre-approve the laboratory services. You say that this testing is required to determine if 
it is necessary to continue anticoagulant therapy for life or if it could be discontinued. The Plan denied your 
request. The Plan says there is not enough evidence to show that using the results of this test to change 
treatment will be effective. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve genetic testing for hereditary thrombophilia (81240, 81241).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on November 18, 2021, to 
December 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were unaware that the Covid waiver changed for 
your OON provider. You also say that you would like the claim to be covered because you have been unable to 
find an in-network pain management provider that accepts new patients. 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 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 an office visit (99213) provided on November 18, 
2021, to December 16, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 28, 2020 
 
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. 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 these 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 the drug testing rendered on December 28, 2020
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a heart surgery procedure (33426, 33464, 33641, 33645, 37799) 
provided on May 5, 2021. 
 
You asked the Plan to pay for heart surgery. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for inpatient hospital services under the 
PPS and that all items and non-physician services furnished to inpatients must be furnished directly by the 
hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of heart surgery have been met. Specifically, the services at issue are physician services. Physician 
services are not included in the payment to the facility. Therefore, we decided that the Plan has to pay for a 
heart surgery procedure (33426, 33464, 33641, 33645, 37799) provided on May 5, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020. 
 
You asked the Plan to pay for the laboratory service. You say that the lab should not be penalized for the 
mismatched issue. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked.  The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus test (U0003) provided on December 21, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for quantitative sensory testing provided on March 4, 2021. 
 
You asked the Plan to pay for quantitative sensory testing. The Plan denied your request. The Plan says the 
clinical value and effectiveness of quantitative sensory testing in the setting of mild peripheral neuropathy have 
not been demonstrated in the peer-reviewed literature. 
 
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 quantitative sensory testing. Our reviewer 
says that the requested quantitative sensory testing is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 68-year-old male with diabetes and mild neuropathy. Quantitative sensory testing (QST), used with increasing frequency especially in clinical therapeutic trials, 
measures sensory thresholds for pain, touch, vibration, and hot and cold temperature sensations. There is no 
specific clinical indication for the requested testing. The review has determined that the requested quantitative 
sensory testing 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 quantitative sensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for quantitative sensory testing provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on 
October 20, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says screening 
asymptomatic patients is excluded. 
 
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. 
 
We looked at the file and the rules. The records show that the enrollees conditions are controlled by 
medications. The testing was ordered to determine the enrollees risk, and not due to a specific problem or 
treatment strategy. Medicare does not cover this test for screening purposes. Therefore, we decided that the 
Plan does not have to pay for the comprehensive cardiovascular gene panel provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 10, 2021. 
 You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 71045 and 32557. 
 
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 71045 
is a column II code to column I code 32557. 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 chest x-ray (71045) provided on September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Glutathione, intravenous (J3490 x 5) provided 
from November 16, 2021, to November 22, 2021. 
 
You asked the Plan to reimburse you for the unclassified drugs. You say that you have a preauthorization for 
this claim. You also say that this is a medical claim, not a prescription. The Plan denied your request. The Plan 
says the pharmacy in this case is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the Glutathione, intravenous 
(J3490 x 5) provided from November 16, 2021, to November 22, 2021.