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

 
We decided that the Plan does not have to pay for an ultrasound provided on November 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that you have done studies at the facility before and even 
though you knew they were an out-of-network provider you like there service they provide. The Plan denied 
your request. The Plan says the rendering provider is an out-of-network provider, and the enrollee did not 
request prior authorization. Also, there is a list of in-network providers near the enrollees residence that 
provide the same quality of service. 
 
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 ultrasound provided on November 5, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5226) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you would like the denture to be 
covered. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the 
mandibular partial denture (D5226) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement lower extremity prosthesis with an 
upgraded cover, vacuum socket, and a new alignable system. 
 You asked the Plan to pre-approve a replacement lower extremity prosthesis with an upgraded cover, vacuum 
socket, and a new alignable system.. You say that the items are medically necessary. The Plan denied your 
request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Payment may be made for the replacement of a 
prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines 
that the replacement device or part is necessary because of any of the following: 
1. A change in the physiological condition of the patient; 
2. An irreparable change in the condition of the device, or in a part of the device; or 
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be 
more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. 
 
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 replacement lower extremity 
prosthesis with an upgraded cover, vacuum socket, and a new alignable system. Our reviewer says that the 
items are not medically necessary. Our physician reviewer found the medical documentation does not support 
that the member requires a replacement prosthesis with an upgraded cover, vacuum socket and a new alignable 
system. He was given a new socket recently with an alignable system and there is no indication for a 
replacement. There is no documentation to support that the prosthesis, that is less than 5 years old, cannot be 
fixed. There is no indication that the member requires an upgraded outer surface covering system or that he is 
exposed to unusually harsh environments. 
 
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 replacement lower extremity prosthesis with an upgraded cover, vacuum 
socket, and a new alignable system. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a replacement lower extremity prosthesis with an upgraded cover, vacuum socket, and a new 
alignable system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 11, 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 you 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 September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on September 29, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for 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 hospital outpatient clinic visit provided on 
September 29, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx test (81551) provided on December 20, 2021. 
 
You asked the Plan to pay for ConfirmMDx test. You say that you are the sole source provider for the 
ConfirmMDx test. This test cannot be performed at a contracted laboratory. The Plan denied your request. The 
Plan says the records do not support that the enrollee meets the Medicare criteria. 
 
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 ConfirmMDx test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CMS Guidelines recommend a repeat (2nd) biopsy in this clinical situation where false 
negative biopsy results are suspected prior to considering genetic testing which was not documented as having 
been completed. Therefore, the ConfirmMDx test will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ConfirmMDx test have not been met. Therefore, we decided that the Plan does 
not have to pay for ConfirmMDx test (81551) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair 
(E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the expandable controller for a power wheelchair. You say that the 
expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
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 expandable controller for a power 
wheelchair. Our reviewer says that the expandable controller is not medically necessary. Our physician 
reviewer found upper limb strength and function are adequate for the enrollee to be able to control the power 
options using their own switches which are included in the allowance of the approved power options. 
 
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 expandable controller for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2377, 
E2313, E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy, a procedure 
that removes pieces of the spine to prevent pressure on the spinal cord. 
 
You asked the Plan to pre-approve the percutaneous laminotomy/laminectomy, a procedure that removes 
pieces of the spine to prevent pressure on the spinal cord. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not 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 percutaneous 
laminotomy/laminectomy, a procedure that removes pieces of the spine to prevent pressure on the spinal cord. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found this service is experimental and more research is needed to prove it safety and 
efficacy. 
 
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 percutaneous laminotomy/laminectomy, a procedure that removes pieces of 
the spine to prevent pressure on the spinal cord have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous laminotomy/laminectomy, a procedure that removes pieces of the spine 
to prevent pressure on the spinal cord.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 8, 2020, to April 
17, 2020, as billed with Diagnosis Related Group (DRG) 660. 
 
You asked the Plan to pay for inpatient care billed with DRG 660. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 660 is not supported as the diagnoses of acute pyelonephritis (N10) and hydronephrosis 
with renal and ureteral calculous obstruction (N13.2) are not supported in the medical record. The Plan argues 
that DRG 661 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 660. Our 
reviewer says that the billing of acute pyelonephritis (N10) and hydronephrosis with renal and ureteral 
calculous obstruction (N13.2) is not supported in this case. Our physician reviewer found that the enrollee was 
treated in the hospital with a urinary tract infection (UTI). She was treated with intravenous antibiotics. 
Imaging showed hydronephrosis and stones on right. Cystoscopy with laser fragmentation of stone with stent 
placement was performed. Based on the enrollee having tones causing UTI, pynephrosis is the most appropriate 
code. However, the diagnoses of acute pyelonephritis (N10) and hydronephrosis with renal and ureteral 
calculous obstruction (N13.2) are not separately supported in the medical record as pyonephrosis already 
describes the infection and stone involvement in one code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 660 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 8, 2020, to April 17, 2020, as 
billed with Diagnosis Related Group (DRG) 660.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) 
provided on February 3, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you cannot pay this 
amount. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the 
frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on February 3, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) provided on February 3, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0398) or pay more for the 
emergency ambulance transportation (A0427) and ground mileage (A0425) provided on March 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine disposable supplies and to pay more for the emergency ambulance 
transportation and ground mileage. You say that you live on a fixed income which makes it extremely difficult 
to pay for anything above what you already pay for your insurance. The Plan denied your request. The Plan 
says the copayment amount that you are being charged for the emergency ambulance transportation and ground 
mileage is correct. The Plan also says that routine disposable supplies are no longer paid separately for 
ambulance services. 
 
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 $265 
copayment for Ambulance services. Medicare rules also say that payment under the fee schedule for ambulance 
services precludes a separate payment for items and services furnished under the ambulance benefit. 
 
You have been asked to pay a $265 copayment for the emergency ambulance transportation and ground 
mileage. The emergency ambulance transportation and ground mileage fall within the Ambulance services 
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. The 
routine disposable supplies also cannot be billed separately. Therefore, we decided that the Plan does not have 
to pay for the routine disposable supplies (A0398) or pay more for the emergency ambulance transportation 
(A0427) and ground mileage (A0425) provided on March 20, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99221) provided on October 11, 2020. 
 
You asked the Plan to pay for initial hospital care. You say that this service is supported in the medical record. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 99223 and 99221. This code does not allow for a modifier to bypass the 
edit. 
 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 99221 
is a column II code to column I code 99223. This code pair does not allow for a 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 initial hospital care (99221) provided on October 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the suction assisted lipectomy, excessive skin and 
subcutaneous tissue and breast augmentation. 
 
You asked the Plan to pre-approve the suction assisted lipectomy, excessive skin and subcutaneous tissue and 
breast augmentation. You say that you get rashes underneath your lower stomach, and it takes 8 weeks to heal. 
You say that this procedure should be covered and would be easier if it was done soon. The Plan denied your 
request. The Plan says the requested procedures are cosmetic in nature and are not covered. 
 
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 suction assisted lipectomy, 
excessive skin and subcutaneous tissue and breast augmentation. Our reviewer says that the coverage criteria 
are not satisfied, and the requested services are not recommended. Our physician reviewer found that the record 
does not indicate that the enrollee has failed conservative treatment for the dermatitis and that a bra strap breast 
lip is planned. The record supports the requested procedures are for cosmetic purposes. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules.  
 
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 suction assisted lipectomy, excessive skin and subcutaneous tissue and 
breast augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
suction assisted lipectomy, excessive skin and subcutaneous tissue and breast augmentation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amphetamine/Dextroamphetamine. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 
Amphetamine/Dextroamphetamine.  
 
 Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal surgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the spinal surgery services. You say that it is necessary for these services to 
be performed by an OON provider. The Plan denied your request. The Plan says this medical care is available 
within the Plan's 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the spinal surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Accu-Check Guide Test strips to be purchased at a 
pharmacy. 
 
You asked the Plan to pre-approve Accu-Check Guide Test strips. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the non-preferred item requested is not covered when 
purchased at a pharmacy, your doctor will need to send in a request for this supply as durable medical 
equipment (DME). 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Accu-Check Guide Test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Accu-Check Guide Test strips to be purchased at a pharmacy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on October 19, 2021.