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

 
We decided that the Plan does not have to pay for Cxbladder detect (0013M) provided January 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with this decision that the 
Cxbladder Monitor test is considered not medically necessary. The Plan denied your request. The Plan says this 
service does not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. CxBladder Detect has not been evaluated for Medicare coverage by 
the MolDx Program administered by Palmetto GBA. Only CxBladder Monitor has been evaluated and it is 
noncovered. This test is then considered non-covered by Medicare using the Palmetto Molecular Diagnostics 
Program Manual.  Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for Cxbladder detect (0013M) 
provided January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient endoscopic procedure 
provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for an outpatient endoscopic procedure. You say that you should 
not have to pay this copayment. The Plan denied your request. The Plan says the copayment applied was 
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 a $275 
copayment for outpatient hospital services.  
 
You have been asked to pay a $275 copayment for an outpatient endoscopic procedure. An outpatient 
endoscopic procedure falls within the Outpatient Hospital Services for Surgery in an Outpatient Setting 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 an outpatient endoscopic procedure provided 
on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LinQ sacroiliac (SI) joint stabilization system. 
 
You asked the Plan to pre-approve a LinQ SI joint stabilization system. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a LinQ SI joint stabilization system. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures directed at the SI joint. The examination does not demonstrate a positive Fortins 
point, Gaenslen's test or a cluster of 3 provocative tests. The imaging studies were unremarkable for SI joint 
pathology. Additionally, the imaging studies do not rule out lumbar pathology. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a LinQ SI joint stabilization system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a LinQ sacroiliac (SI) joint stabilization system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on March 9, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you shouldn't have to pay this charge. 
The Plan denied your request. The Plan says the copayment applied 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 $20 
copayment for each primary care physician's office visit.  
 
You have been asked to pay $20 copayment for office visit. Office visits fall within the Physician/Practitioner 
Services, Including Doctor's Office Visits 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 office visit provided on March 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 1, 
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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed items/services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for these services have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency room (ER) services rendered on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an office visit provided on March 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), lenses (V2781, V2784), and anti-reflective 
coating (V2750) received on March 28, 2022, by an out-of-network provider. 
 You asked the Plan to pay for frames, lenses, and anti-reflective coating by an out-of-network provider. You 
say that you were told the services would be covered. The Plan denied your request. The Plan says theres no 
coverage for services that are rendered by an out-of-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of frames, lenses, and anti-reflective coating by an out-of-network provider have not been met. 
Therefore, we decided that the Plan does not have to pay for frames (V2020), lenses (V2781, V2784), and anti-
reflective coating (V2750) received on March 28, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair repairs. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the Plan. 
 
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 wheelchair repairs have not been met. The power wheelchair is 
within the 5-year reasonable useful lifetime, and this was not a case of loss or irreparable damage from a single 
event, replacement is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on September 30, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee injections provided on May 26, 2022. 
 
You asked the Plan to waive the coinsurance for knee injections. You say that you were unaware of the 
coinsurance and therefore should not have to pay for it. The Plan denied your request. The Plan says the 
coinsurance applied was 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 a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item is $1219 resulting in a 
coinsurance amount of $243.80 ($1219 x 20% = $243.80). 
 
You have been asked to pay a $243.80 coinsurance for knee injections. Knee injections fall within the 
Medicare Part B Prescription Drugs 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 coinsurance for 
knee injections provided on May 26, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dalvance 500MG vial (CPT code J0875). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the medication. Our physician reviewer 
found bacteremia/sepsis with Staphylococcus Hominis without evidence of a skin or skin structure infection is 
not a FDA-approved indication for use of Dalvance. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Dalvance 500MG vial (CPT code J0875).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 10, 
2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services to the member in good faith. The Plan denied your request. The Plan says with the 
information we have, we 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 subsequent nursing facility care 
provided on September 10, 2021 have been met. Therefore, we decided that the Plan does not have to pay for 
subsequent nursing facility care provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment program (OTP) services (G2067) provided from 
March 3, 2022, to March 28, 2022. 
 
You asked the Plan to pay for OTP services. You say that this facility is a certified provider, and these services 
should be covered. The Plan denied your request. The Plan says that this claim can be considered for payment 
when received with the Type of Bill (TOB) 87x. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for opioid treatment program (OTP) 
services are submitted using the 837P transaction to transmit health care claims electronically, procedure codes 
G2067-G2075, and Place of Service (POS) code 58. 
 
We looked at the file and Medicare rules. The services at issue were billed with code G2067 and POS 58 on an 
837 claim form as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of OTP services have been met. Therefore, we decided that the Plan has to pay for opioid treatment 
program (OTP) services (G2067) provided from March 3, 2022, to March 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Biolab Membrane Wrap (human amniotic allograft 
membrane). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested Biolab Membrane Wrap (human amniotic allograft membrane) is 
unproven and not medically necessary due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has a nonhealing gluteal ulcer with minimal granulation. 
There is insufficient evidence to establish the safety and efficacy of the requested service for the enrollee's 
clinical condition. The record provided does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Biolab Membrane Wrap (human amniotic allograft membrane).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter placement of intracoronary 
stent(s), with coronary angioplasty when performed; single major coronary artery or branch (CPT code 92928). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee could have serious health problems if 
the stent is not put in, the enrollee's heart could get clogged which would result in a heart attack and dying. The 
Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records 
show the enrollee does not have symptoms of angina or objective evidence of myocardial ischemia. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our physician reviewer 
found guidelines do not support a need for cardiac catheterization with coronary angioplasty and stent 
placement in this setting. As a result, at this time cardiac catheterization with coronary angioplasty and stent 
placement would not be considered medically appropriate and necessary in this enrollees 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty 
when performed; single major coronary artery or branch (CPT code 92928).