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

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed for March 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that if the professional interpretation was furnished in a 
different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test 
must be separately billed with modifier -26. 
 
We looked at the file and Medicare rules. Billed procedure codes 88360 and 88381 have a PC/TC indicator of 
1. The file shows that the services were billed with place of service code 22 for an outpatient hospital. The file 
does not show that the PC and TC were performed in different payment localities. Therefore, we decided that 
the Plan does not have to pay for procedure codes 88360 and 88381 billed for March 4, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox (onabotulinumtoxinA) injections. 
 
You asked the Plan to pre-approve the requested Botox treatment. You say that this treatment is needed to treat 
rectal outlet obstruction as other treatments have not been helpful. The Plan denied your request. The Plan says 
that this treatment is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested Botox treatment. Our 
reviewer says that the documentation supports that this treatment is medically reasonable and necessary for the 
enrollee's condition. Our physician reviewer found the provided medical records document that the enrollee in 
this case has evidence of puborectalis muscle dyssynergia on a dynamic pelvic floor magnetic resonance scan 
with a history of chronic constipation resistant to multiple therapies. Micromedex has a favorable citation for 
off-label use of Botox injections into the puborectalis muscle for pelvic floor dyssynergia for short-term 
treatment of intractable constipation. Under Medicare rules any positive citation in the Medicare-approved 
compendia is adequate for designation of a medically accepted indication. 
 
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 requested Botox treatment have been met. Therefore, we decided that the 
Plan has to pre-approve Botox (onabotulinumtoxinA) injections.  
 
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 urinary tract infection (UTI) panel (87481, 87556, 87641 
and 87798) provided on September 28, 2022. 
 
You asked the Plan to pay for the UTI panel. You say that this test was performed by a certified laboratory and 
was referred by the enrollee's treating physician. The Plan denied your request. The Plan says this panel was 
not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) panel (87481, 
87556, 87641 and 87798) provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions in an outpatient hospital setting. 
 
You asked the Plan to pre-approve dental extractions. You say that this should be covered. The Plan denied 
your request. The Plan says extractions due to decay or periodontal disease or for the purpose to obtain 
dentures is not a covered benefit. 
 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions in an outpatient hospital setting.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine provided on October 28, 2022. 
 
You asked the Plan to pay for the drug. You say that this is needed for treatment of neck pain. The Plan denied 
your request. The Plan says more details are needed to determine if these charges are eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug. Our reviewer says that the services 
at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the patient 
has neck pain related to cervical spondylosis without radiculopathy. A bupivacaine injection (diagnostic 
cervical facet nerve block) was provided on October 28, 2022. However, the provided documentation describes 
this procedure already being covered and paid for separately, making this independent request for bupivacaine 
which was part of the procedure, no significant or separately identifiable and will be considered redundant and 
not appropriate. 
 
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 pay for Bupivacaine provided on October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization procedures for the lower extremities. 
 
You asked the Plan to pre-approve the requested revascularization. You say that the requested services are 
necessary for the enrollee's condition. The Plan denied your request. The Plan says these procedures are not 
supported as there are not severe symptoms, and other treatments would be more appropriate. 
 
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 requested revascularization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the description of the enrollee's symptoms in the records provided is inadequate 
for the purpose of determining the etiology of the condition. The enrollee has a history of 3 back surgeries and, 
therefore, there may likely be a neurogenic component to her leg symptoms. This is further supported by the 
fact that on the left only isolated anterior tibial disease is identified. There does not appear to be an 
ankle/brachial index (ABI) result. It is also unclear how the enrollee completed a recent claudication exercise 
regimen if she is recently status post coronary bypass surgery. At this time, there is no evidence of limb threat 
documented. As such, the surgery requested is not supported as medically 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 the requested revascularization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve revascularization procedures for the lower extremities.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 
billed for date of service August 20, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381. You say that these 
services were reported correctly. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377 and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377 and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377 and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 billed for date 
of service August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for application of a modality 
(requiring constant provider attendance) to one or more areas; low- level laser provided from October 14, 2022, 
to October 26, 2022. 
 
You asked the Plan to reimburse you for application of a modality (requiring constant provider attendance) to 
one or more areas; low- level laser. The Plan denied your request. The Plan says this provider does not 
participate with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that this barbershop does not participate in the 
Medicare program. Therefore, we decided that the Plan does not have to reimburse you for application of a 
modality (requiring constant provider attendance) to one or more areas; low- level laser provided from 
October 14, 2022, to October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code K0606 provided on October 30, 2021. 
 
You asked the Plan to pay for procedure code K0606. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
guidelines. 
 
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 procedure code K0606 was not filed until November 3, 2022. 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 procedure code K0606 provided on October 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and LTACH will have the needed services to fully recover and successfully regain maximum independence. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met, the 
enrollee's medical needs are being met in the current acute setting and LTACH would add no additional 
services. With additional time in the current setting, clinical stability can be ensured such that the appropriate 
lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital and does 
not require services at the LTACH that are not available at the current acute care hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Inogen portable oxygen concentrator and backpack 
provided on April 27, 2022. 
 
You asked the Plan to pay for the Inogen portable oxygen concentrator and backpack. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of 
payment for this item is correct because purchased oxygen equipment is not covered under Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage and purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided 
that the Plan does not have to pay for the Inogen portable oxygen concentrator and backpack provided on April 
27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided on August 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on August 23, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound-care supplies (A4450, A6213, A6402) billed for date 
of service August 16, 2022. 
 
You asked the Plan to pay for wound-care supplies. You say that the supplies at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for wound-care supplies (A4450, A6213, A6402) 
billed for date of service August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult sized disposable incontinence product, protective 
underwear/pull-on (T4528). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says disposable underwear/pull-ups is not covered under your plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult sized disposable 
incontinence product, protective underwear/pull-on (T4528).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery 
pressure monitor. 
 
You asked the Plan to pre-approve the CardioMEMs procedure. You say that there is substantial evidence to 
support the usefulness of this treatment. The Plan denied your request. The Plan says there is not enough 
evidence to support that this treatment is medically necessary. 
 
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 CardioMEMs procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. 
 
Nonetheless, there remains a lack of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee'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 CardioMEMs procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery pressure monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile mileage limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation. The Plan denied your request. The Plan says the requested trip exceeds the routine 
transportation mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile mileage limit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic testing (81225, 81226, 81227, 81230, 
81231, 81381) provided on October 13, 2022. 
 You asked the Plan to pay for pharmacogenomic testing. You say that this testing was necessary, and you did 
not expect to be responsible for such a large cost. The Plan denied your request. The Plan says there is 
insufficient information in the medical records to support the necessity of this test. 
 
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 pharmacogenomic testing have been 
met. Specifically, the medical records provided do not show any intention to have this test performed. The 
medical records note that there is no intention to adjust medications, as these are being managed by another 
provider. Records from this other provider were not submitted. It is unclear how this test is intended to impact 
your treatment. Therefore, we decided that the Plan does not have to pay for pharmacogenomic testing (81225, 
81226, 81227, 81230, 81231, 81381) provided on October 13, 2022.