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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of truncal edema. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has lymphedema. The record indicates that the enrollee has critical 
limb ischemia with a Rutherford class V score. The record does not document the presence of abdominal or 
truncal edema in any examination. The record does not indicate that the enrollee has failed treatment after a 
four week trial with a basic pump. The elements of the coverage rules are not satisfied. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services in addition to basic services provided (99053) 
provided on September 16, 2021. 
 
You asked the Plan to pay for the services in addition to basic services (99053). You say that medical records 
are attached for review of payment. The Plan denied your request. The Plan says bundled services are not 
eligible for separate reimbursement. 
 
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, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
  We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services in addition to basic services 
(99053) have not been met. Therefore, we decided that the Plan does not have to pay for the services in 
addition to basic services provided (99053) provided on September 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 
70450) provided on September 12, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 CT, head or brain; without contrast material (CPT code 70450) 
provided on September 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01210) provided on September 9, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that this should be covered. The Plan denied your 
request. The Plan says medical records to support this service have not been submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also 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 find that CPT code 01210 is not supported in the medical record. Specifically, medical records 
documenting this service have not been submitted. Based on this information, we decided that Medicare rules 
for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services (01210) provided on September 9, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxorubicin Liposome for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted doesn't meet the plan's medical necessity and step therapy 
guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the provided 
documentation did not clearly show that the enrollee had tried and failed anthracycline-based therapy, 
conventional doxofubicin or epirubicin-based therapy. Also, there was insufficient explanation provided in the 
documentation to show that these preferred medications would be contraindicated or be less effective for this 
enrollee's condition. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Doxorubicin Liposome for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on June 21, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says this 
claim was billed with the incorrect place of service code. 
 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 Guardant360 testing 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 Guardant360 testing (81479) provided on June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code 
70544) provided on July 11, 2021. 
 
You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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. In this case, we have confirmed that code 70544 
is a column II code to column I code 70551. 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 MRA, head; without contrast material(s) (CPT code 70544) 
provided on July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 28, 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 codes 71045 and 32555. 
 
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 32555. 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 July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided on August 23, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for the chest x-ray. You say that there were two claims with CPT 71045 but for two 
different providers. The Plan denied your request. The Plan says with the information they have, the Plan 
cannot determine how the member came to the servicing provider or whether the services are medically 
necessary. 
 
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 chest x-ray (CPT code 71045) 
provided on August 23, 2021. No medical records were received by the provider to verify if the services were 
necessary. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) 
provided on August 23, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the head or brain CT scan (CPT code 70450) provided on 
October 28, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 head or brain CT scan (CPT code 70450) provided on 
October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 25, 2021. 
 You asked the Plan to pay for the services provided. You say that the test was prescribed in good faith. The 
Plan denied your request. The Plan says the screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that a complete urinary tract infection panel was provided. The records do not show how the 
testing will impact the clinical management of the enrollee. The test at issue appears to have been requested for 
screening purposes. There are insufficient medical records to show the testing was ordered due to signs and/or 
symptoms. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the lab testing services provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept intraosseous nerve ablation procedure 
(64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the intracept procedure is safe, 
efficacious, durable and reproducible for appropriately selected patients. The Plan denied your request. The 
Plan says this is considered experimental and investigational. It is not an accepted standard of medical practice 
for the diagnosis or treatment of back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept intraosseous nerve ablation procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on June 
13, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81479 remains 
not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient 
when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in 
a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on June 3, 2021, and received by the lab on June 4, 2021. Of note, the patient resides in 
Pennsylvania and the billing laboratory is located in California; therefore, the billed code cannot be verified. It 
is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on June 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 14, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing is detrimental to the enrollee's health 
and recovery. The Plan denied your request. The Plan says the billed codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim lists a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. 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 drug testing services provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes (97810) provided on 
October 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acupuncture services. You say that in accordance with Medicare guidelines, 
this service should be allowed. You were told it is covered up to 12 treatments for 2021 and 20 treatments for 
2022. It is written in the Plan's book. The Plan denied your request. The Plan says there is no coverage for 
routine acupuncture services. 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 acupuncture, initial 15 minutes (97810) 
provided on October 6, 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 lab testing services provided on July 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were compliant with the regulations. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not show that the specimen was obtained at the independent laboratory. 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 lab testing services provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #19. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says that tooth #19 has 
lost over 50% of the distal bone support and bone support between the roots as well as having an infection 
under one of its roots in the bone. The Plan also says that this renders the tooth with a very poor to hopeless 
prognosis. 
 
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 did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for 
tooth #19.  
 
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 Guardant360 panel (CPT code(s): 81406 x2, 81405 x2, 
81404 x2, 81403 x2, 81402, 81401 x2, 81400, 81321, 81318, 81314, 81311, 81310, 81309, 81299, 81293, 
81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, and 81120) provided on September 8, 2021. 
 You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Guardant360 test should be reported with CPT 81479. The Plan 
states they will approve a request if the appropriate CPT code 0242U, is submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The Guardant360 test should be reported with 
CPT code 81479. 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 the Guardant360 panel 
(CPT code(s): 81406 x2, 81405 x2, 81404 x2, 81403 x2, 81402, 81401 x2, 81400, 81321, 81318, 81314, 
81311, 81310, 81309, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, and 
81120) provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not show that the specimen was obtained at the independent laboratory. 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 lab testing services provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says these services were 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 June 30, 2021.