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

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on April 7, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the diagnosis code does not substantiate this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the documentation submitted on appeal indicates the cardiovascular genetic 
screening panel was initiated by the laboratory and not by the enrollee's treating physician nor following a 
consultation or evaluation by the enrollee's treating physician. The review has determined that the services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported 
 
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 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 drug testing services provided to the enrollee on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on October 27, 2021. 
 
You asked the Plan to pay for eyewear. The Plan denied your request. The Plan says the eyewear was provided 
by an out-of-network provider and prior authorization was not obtained. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows the eyewear was not provided by a Plan vision 
provider. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for eyewear provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 18, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says multiple attempts were made to obtain supporting documentation of the anesthesia/operative 
session that was billed for 33 units on date of service 08/18/2021. 
 
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 00731 is "Anesthesia for upper gastrointestinal 
endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found CPT code 00731 has a basic value of 
5 Base Units (the value assigned by Medicare to each anesthesia procedure code). The medical records indicate 
that the procedure medications included Propofol 140mg for sedation. The IV sedation/ MAC/anesthesia services were provided from 0647-0703 (14 minutes). Every 15 minutes of time equals 1 unit.  The anesthesia 
services provided should be billed: 5 base units + 1 unit (time) = 6 total units (multiplied by the conversion 
factor/RVU/per insurance company). The review of the medical records do not support that 33 units should be 
billed for the anesthesia services provided for CPT code 00731 (0647-0703) on 8/18/2021. 
 
We looked at this coder'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 pay for anesthesia services provided to the enrollee on August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine (J3490). 
 
You asked the Plan to pre-approve Buprenorphine. You say that the enrollee is stable on this medication, and 
this is a continuation of care. The Plan denied your request. The Plan says this drug is not covered for the 
enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Buprenorphine (J3490).  
 
 
 
 Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on December 6, 
2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you thought the endoscopy would 
be a specialist visit with a $35 copayment. You were not aware this would be a surgery charge. The Plan 
denied your request. The Plan says copayment is correct. 
 
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 $245 
copayment per date of service at an in-network ambulatory surgical center. 
 
You have been asked to pay $245 copayment for the endoscopy. The endoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the endoscopy provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood pressure monitor received on December 14, 2021. 
 
You asked the Plan to pay for the monitor. You say that you were told that you would get reimbursed 40% of 
the total cost. The Plan denied your request. The Plan says a prescription is required from the Primary Care 
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 a blood pressure monitor received on December 
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tape (A4450) provided April 8, 2021 
 
You asked the Plan to pay for the tape. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the code is not eligible for payment. 
 
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 CPT code A4450 is not eligible for payment per the DME Fee Schedule. This means that CPT 
code A4450 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the tape have not been met. Therefore, we decided that the Plan does not have to pay for tape 
(A4450) provided April 8, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (87635) provided on November 11, 2021 
by an out-of-network (OON) provider while out of the Country. 
 
You asked the Plan to pay for COVID-19 testing. You say that this COVID test was medically mandated by the 
US government shortly before your return to the US. The US government mandates COVID tests 
reimbursement by insurance companies. 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. 
COVID testing for social purposes such as travel is not covered. 
 
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 COVID-19 testing (87635) provided on November 
11, 2021 by an out-of-network (OON) provider while out of the Country.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multi-level injection (procedure code 64495) provided to 
the enrollee on March 25, 2021. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed, as there is no support for an injection of three 
additional levels. 
 
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 64495 is "Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure)." 
 
We asked our coder 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 injection. Our reviewer says that the services at issue in 
this case were not supported by the medical records.  Our reviewer found that according to the medical records submitted, the procedure note does not support an 
injection at three levels. The medical records indicate that a nerve block was only given at a total of two levels; 
therefore, the additional billed level and modifier isn't supported. The review has determined that the records 
did not support that a three-level injection was rendered in the case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a multi-level injection (procedure code 64495) provided to the enrollee on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on August 
2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted indicates that assistant surgical services were performed by a 
Surgical Assistant. 
 
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 provided 
to the enrollee on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reclining lift chair provided on August 27, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a reclining lift chair. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 a reclining lift chair provided on August 27, 2021 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on November 
19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate diagnoses were not used. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
November 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service January 19, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 procedure code 76700 billed for date of service January 19, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you were admitted for surgical repair of a hip fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not 
a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance provided to the enrollee on September 
21, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says an 
appropriate modifier was not billed in this case. 
 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 77003 
is a column II code to column I code 64493. 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 fluoroscopic guidance provided to the enrollee on September 21, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that you would like Eylea to be considered so you can 
proceed with the proper care for this enrollee. The Plan denied your request. The Plan says Eylea is denied 
because there is no trial or failure of Avastin. 
 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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary. Our physician reviewer found there is no indication that the patient has 
tried and failed the required drug, Avastin. Our reviewer also found that there is no indication that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 5, 2021, to November 5, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the criteria for this admission was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not qualify for SNF coverage. 
The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled 
therapy needs. Daily skilled services were not shown to be required to establish a maintenance program or to 
prevent deterioration of the enrollees 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 5, 2021, to 
November 5, 2021.