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

 
We decided that the Plan does not have to pay for the at-home covid-19 test, provided on December 21, 2021. 
 
You asked the Plan to pay for the at-home covid-19 test. You say that the items should be covered. The Plan 
denied your request. The Plan says Medicare does not pay for at-home tests. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home covid-19 test have not been met. Specifically, people covered by original fee-for-
service Medicare, Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and 
antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician 
practitioner, pharmacist, or other authorized health care professional. People with Medicare can access one lab 
performed test without cost sharing per patient per year without an order. At this time original Medicare cannot 
pay for at-home tests through this program. Medicare Advantage plans may offer coverage and payment for at-
home over- the-counter COVID-19 tests, so consumers covered by Medicare Advantage should check with 
their plan. Therefore, we decided that the Plan does not have to pay for the at-home covid-19 test, provided on 
December 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 60 minutes with patient (90837), 
provided on August 12, 2021, to September 15, 2021. 
 
You asked the Plan to pay for the psychotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says you did not use a Medicare qualified mental health provider for this service. 
 
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 pay for the psychotherapy, 60 minutes with 
patient (90837), provided on August 12, 2021, to September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital visit (99231), provided on September 
28, 2020. 
 
You asked the Plan to pay for the outpatient hospital visit. You say that the service should be covered. The Plan 
denied your request. The Plan says the claim waas filed 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 the outpatient hospital visit was not filed until December 15, 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 the outpatient hospital visit (99231), provided on 
September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating pump and pad (E0236 and E0249), 
provided on July 14, 2021, to August 11, 2021. 
 
You asked the Plan to pay for the water circulating pump and pad. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that because a water circulating heating pad system is 
not medically necessary, a replacement pump (E0236) or pad (E0249, A9999) will be denied as not reasonable 
and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating pump and pad have not been met. Therefore, we decided that the Plan does 
not have to pay for the water circulating pump and pad (E0236 and E0249), provided on July 14, 2021, to 
August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding scooter (K0899). 
 
You asked the Plan to pre-approve a folding scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) or power 
wheelchair (PWC) which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor 
or which has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be 
denied as not reasonable and necessary and should be coded as K0899 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a folding scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a folding scooter (K0899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the harness (E2313), electronic connection (E2311), 
expandable controller (E2377), and power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says it is not medically necessary to control power options through a 
joystick and a power seat elevation system does not primarily serve a medical purpose. 
 
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 wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records document that the enrollee has the upper extremity strength and 
is able to feed herself with set-up assistance thus indicating she has adequate upper extremity strength and 
function to operate the wheelchairs power options with their own switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the harness (E2313), electronic connection (E2311), expandable controller 
(E2377), and power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 1, 2021. 
 You asked the Plan to pay for the services provided. You say that the medical records support the billing 
location. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim at issue was billed with an outpatient hospital place of service 
code. We find that the enrollee was receiving inpatient care at the time the services were provided. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on March 1, 2021. 
 
You asked the Plan to pay for lab tests. You say that the treating physician ordered this testing as a medically 
necessary and valuable tool to determine treatment for the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because the documentation submitted does not support the 
Place of Service (POS) code billed on this 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 lab tests 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 laboratory testing provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the covid-19 at-home test, provided on January 30, 2022, to 
February 17, 2022. 
 
You asked the Plan to pay for the covid-19 at-home test. You say that the item should be covered. The Plan 
denied your request. The Plan says as at-home/over-the-counter (OTC) COVID-19 diagnostic tests (including 
FlowFlex COVID-19 Antigen Home Test) are not covered under Original Medicare and are not listed as 
covered in your EOC, they are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the covid-19 at-home test have not been met. Therefore, we decided that the Plan does not have to 
pay for the covid-19 at-home test, provided on January 30, 2022, to February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq for the enrollee. 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of monotherapy Tecentriq in the setting of a 
Child-Pugh Class B patient have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq. Our reviewer says that 
Tecentriq is not medically reasonable and necessary for the enrollee. Tecentriq is not FDA-approved for the 
enrollees diagnosis. There is no clear documentation if Tecentriq is being used for hepatocellular carcinoma or 
bladder cancer. Neither of these diagnoses has enough documentation to support use. The use of Tecentriq is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical procedure (15004,14301) provided on 
January 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical procedure. You say that as the provider is in network and no 
authorization was required and the severity of is diagnosis, the care provided is medically necessary and should 
be covered. 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 the outpatient surgical procedure (15004,14301) 
provided on January 11, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
without contrast material (70450) and with contrast material (70470) provided on December 7, 2021. 
 You asked the Plan to pay for CT scans of the head or brain with and without contrast material. You say that 
you have provided records to support the level of service. The Plan denied your request. The Plan says rules for 
payment have not been met because the CPT codes at issue are inclusive to another billed code. 
 
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 70470 
is a column II code to column I code 0042T. Furthermore, code 70450 us a column II code to column I code 
70470. These claims have not been billed with appropriate modifiers to bypass the edits. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for a computed tomography (CT) scan of the head or brain without contrast material (70450) and with 
contrast material (70470) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 24, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this 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 lab tests 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 laboratory testing provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology (81479) Genomic Sequencing 
Procedures and Other Molecular Multianalyte Assays (81442) provided May 26, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you have attached additional documents to 
support the claim. Medical necessity has been signed off by the ordering physician of which is the enrollee's 
PCP with an ongoing patient relationship. The Plan denied your request. The Plan says the services do not meet 
Medicare coverage criteria. 
 
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. Per outreach to the ordering provider's office, the Plan verified that 
the provider did not order cardiovascular genetic testing for the enrollee. The Plan also verified with the lab 
that the cardiovascular genetic testing are to provided to patients via the mail and returned via the mail. Based 
on this information, we decided that Medicare rules for coverage of the laboratory 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 unlisted 
molecular pathology (81479) Genomic Sequencing Procedures and Other Molecular Multianalyte Assays 
(81442) provided May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 7, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
 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. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on February 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on October 20, 2021. 
  You asked the Plan to pay for occupational therapy services. You say that this provider is a non-contracted 
provider and 30% of the billed charges should be paid. The Plan denied your request. The Plan says the code is 
not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a 
physician/non-physician practitioners service must meet all incident requirements. Medicare rules also say that 
the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a 
physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the records do not indicate if the 
rendering provider was an occupational therapist or an OTA. A nurse practitioner is not able to bill for the 
services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse 
practitioner was on the premises to be able to bill for occupational therapy services. Additionally, since the 
record does not include the rendering providers credentials, we are unable to verify the billed services. 
Therefore, we decided that the Plan does not have to pay for occupational therapy services provided on October 
20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM) and supplies. You say that the items 
are medically necessary. The Plan denied your request. The Plan says the member does not use insulin with at 
least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose 
testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor (CGM) and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood 
glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on January 14, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on January 14, 2022.