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

 
We decided that the Plan does not have to pay for mammography services (77063, 77067) provided on 
February 1, 2022. 
 
You asked the Plan to pay for mammography services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
claim at issue is a duplicate of a prior claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mammography services have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does 
not have to pay for mammography services (77063, 77067) provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Epifix skin substitute for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found Epifix skin substitute is medically necessary required to avoid extensive surgery. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Epifix skin substitute for the enrollee.  
 
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: Partially Favorable

 
We decided that the Plan must waive the deductible for the office visit. We decided that the Plan does not have 
to waive the copayment for the office visit.  
 
You asked the Plan to waive the deductible for specialist office visit. You say that you were never charged this 
in the past so it should be covered now. The Plan says that the deductible applied is correct. 
 
 
 
 We decided that the Plan must waive the deductible for the office visit.  
 
The Plan says you must pay $86.22 toward the deductible for the office visit. The 2022 Schedule of Cost 
Sharing lists a deductible for the 2021 Plan year. The Schedule of Cost Sharing does not clearly list a 
deductible for the 2022 Plan year. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the deductible for the office visit.  
 
We also decided that the Plan does not have to waive the copayment for the office visit. 
 
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 $30 
copayment for specialist office visit. Therefore, we decided that the Plan does not have to waive the copayment 
for the office visit. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomography angiography (CTA). 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says an expert review indicates that this is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the symptoms have 
been non-specific, and felt to be non-cardiac in nature, without evident indication for routine cardiac testing. 
Clinical guidelines for the use of coronary CTA have not been met based on review of the submitted clinical 
documentation. As a result, at this time coronary CTA would not be considered medically reasonable and 
necessary in this patient's clinical management. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve coronary computed tomography angiography (CTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Sensor. 
 You asked the Plan to pre-approve a Freestyle Libre 14 Day Sensor. The Plan denied your request. The Plan 
says there is no evidence that the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 Freestyle Libre 14 Day Sensor have 
been met. Specifically, there were no medical records submitted despite the Plan having made reasonable 
attempts to obtain them. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 
Day Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic testing panel provided on 
October 25, 2021. 
 
You asked the Plan to pay for the Genesight Psychotropic testing panel. You say that this is a Medicare-
covered test that should be reprocessed and approved for payment. The Plan denied your request. The Plan says 
there is not sufficient evidence to support this testing is medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods.  Therefore, we 
decided that the Plan does not have to pay for the Genesight Psychotropic testing panel provided on October 
25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is to be used for 
the treatment of COPD. The Plan denied your request. The Plan says the requested ventilator 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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has very severe COPD, 
but there is no documentation of chronic CO2 retention with an ABG done as an outpatient while stable. A 
venous BG in hospital was suggestive of chronic retention. If the enrollee does have chronic CO2 retention, he 
may benefit from bipap support during sleep, with the AVAPS mode. However, the records indicate the 
enrollee is not tolerant of bipap interface. The Life2000 system is not a true ventilator, because it is not capable 
of providing full ventilatory support. It is designed to provide breath-initiated positive pressure oxygen during 
activity. There is inadequate evidence that this device is beneficial in the treatment of COPD. 
 
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 (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
 
 
 
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical vision care (92014, 92015, 92250) provided on 
October 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network vision care. You say that you did not know you needed 
authorization and you had seen this provider in the past. The Plan denied your request. The Plan says out-of-
network care is covered only in certain limited circumstances. The services at issue were not urgent or 
emergent, nor were they pre-approved, and they could have been received from an in-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 medical vision care (92014, 92015, 92250) 
provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place an interspinous process stabilization 
device for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found interspinous process stabization devices remain experimental at this time. 
 
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 surgery have not been met.  
  
 
Therefore, we decided that the Plan does not have to pre-approve surgery to place an interspinous process 
stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve a thermal destruction of intraosseous basivertebral nerve. You say that the 
requested procedure is medically necessary. The Plan denied your request. The Plan says the requested 
procedure does not meet criteria. 
 
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 a thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has documented Modic 
changes at L5. He also has spinal stenosis. This is an experimental/ investigational procedure and there is little 
evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
 
 
 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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical evidence to support the medical necessity of this request. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found sacroiliac joint radiofrequency ablation therapy is experimental for low back pain at this time. 
 
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 pre-approve radiofrequency ablation of the sacroiliac 
joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services for a total knee arthroplasty 
(27447) provided on January 6, 2022. 
 
You asked the Plan to pay for surgical assistant services. You say that the services at issue were a necessity for 
the enrollee's care. The Plan denied your request. The Plan says rules for payment for surgical assistant services 
have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services for a total 
knee arthroplasty (27447) provided on January 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided 
on June 13, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee did not respond with insurance 
information until recently. The Plan denied your request. The Plan says this claim was filed outside of the one 
calendar year limit and therefore is denied as untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ambulance services was not filed until December 8, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided on 
June 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81219, 81270, 81279, 81339, 81479) provided 
August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81219, 81270, 81279, 81339, 81479) 
provided August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on February 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on February 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide (HHA) service hours 
(G0156). 
 
You asked the Plan to pre-approve additional HHA service hours. You say that the enrollee is in need of 
extensive personal care, and their spouse is unable to provide the attention and care the enrollee needs. The 
Plan denied your request. The Plan says this request does not meet criteria for medical necessity. The Plan also 
says that the approved 35 hours a week of HHA care appropriately meets the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
  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 additional HHA service hours. Our 
reviewer says that the number of requested HHA hours is not medically necessary or reasonable. Our physician 
reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. Our reviewer 
found that the enrollee has been approved for 5 hours per day of HHA services to assist with his care needs. 
Our physician reviewer also found that the documentation does not show why additional hours are necessary or 
that such hours would assist in the treatment of an acute illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional HHA service hours have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional home health aide (HHA) service hours (G0156).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray of the chest (71045) provided on October 21, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this claim was denied as a duplicate in error. The Plan 
denied your request. The Plan says that this claim is a duplicate of another claim which has already been 
considered for payment. 
 
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. Specifically, the only reason provided for this denial is that this is a duplicate 
claim. However, the documentation forwarded for review does not include any evidence to show that a claim 
for this same x-ray has already been paid to this provider for the same enrollee and date of service. There is no 
evidence to support that this is a duplicate of a previously paid claim, and there is no other argument or 
supporting evidence to support that this claim should be denied. Therefore, we decided that the Plan has to pay 
for the x-ray of the chest (71045) provided on October 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.