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

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service June 10, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76942 is bundled into payment for 
code 75635. 
 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 76942 
is a column II code to column I code 75635. 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 76942 billed for date of service June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this would be beneficial to managing your 
enrollee's medical condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been met for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult sized disposable incontinence product, brief/diaper 
(T4522). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial and are 
requesting reconsideration for the requested briefs/diapers. The Plan denied your request. The Plan says the 
disposable under-pads are not a covered benefit. 
 
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, brief/diaper (T4522).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 76857. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76857 is bundled into payment for 
code 76775. 
 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 76857 
is a column II code to column I code 76775. 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 76857 billed for date of service June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on March 1, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there is insufficient information to support these services as billed. 
 
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 drug testing have been met. 
Specifically, the documentation submitted does not include a laboratory report or results for the services billed. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bladder control pads. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are working on pelvic floor 
exercises, and you do not want to have surgery. You are requesting a reconsideration for the incontinence pads. 
The Plan denied your request. The Plan says the item in question is not covered under your plan contract under 
any normal circumstances. 
 
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 bladder control pads.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve the requested services. You say that conservative treatments have failed. 
The Plan denied your request. The Plan says the device is not reasonable or 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 requested services. Our physician 
reviewer found that the enrollee has left ventricular dysfunction and continued symptoms, thought to reflect 
congestive heart failure. Several randomized clinical trials have also been reported, along with meta-analysis 
pooling the data from multiple studies, with the device providing meaningful improvement in quality-of-life 
scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, the device 
remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, the device is not considered to be 
medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Optimizer Smart device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the provider is more knowledgeable for your 
condition. The Plan denied your request. The Plan says services are available 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 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 
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 power wheelchair options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not need to control power options through a joystick. 
 The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested. 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 services. Our physician reviewer found that the requested electrical 
accessories are not medically necessary as you do have use of the upper extremity and can operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
The file shows that transfer handles were requested. This item does not serve a purpose that is primarily 
medical in nature. We looked at the physician's review, the file, and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair options.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder placement (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that the loop recorder 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 an implantable loop recorder is used when syncope is 
thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional pre-
symptom loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the requested service is not medically necessary. Our physician reviewer found no 
significant arrhythmias were noted during the hospital admission. There is no evidence of an ambulatory ECG 
monitor having been performed to further assess a possible arrhythmic etiology of syncope. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder placement (33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee has a medically-accepted indication for the use of Aranesp, based on the submitted records and 
Medicare-approved major drug compendia. The use of Aranesp is not considered safe and effective or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the submitted documentation does not 
include an order for a power wheelchair or an evaluation to support that you can adequately use a PWC in the 
home or that you have the capacity to safely operate the PWC. There is no indication that you are unable to use 
a manual wheelchair. The PWC is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 1 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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, for 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 May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have chronic 
respiratory failure due to chronic obstructive pulmonary disease (COPD). The records document that the home 
ventilator is being requested for use in an average volume pressure support (AVAPS) mode with auto-titration, 
which could be provided by a bi-level positive airway pressure (BiPAP) device with AVAPS and a back-up 
rate. The criteria for coverage are not met and therefore the home ventilator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on May 9, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were told by your provider's office 
that there would be no charge for the boot, and you would not have chosen to get the item if you knew about 
the cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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% 
coinsurance for durable medical equipment, covered items, and related supplies.  
 
You have been asked to pay a coinsurance of $47.30, which is 20% of the allowed amount for DME ($236.52 
allowed x 20% = $47.30). This item/service falls within the Durable Medical Equipment (DME) and Related 
Supplies 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 DME provided on May 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the triamcinolone acetonide injection, low 
osmolar contrast material, fluoroscopic guidance, and arthrocentesis provided on April 13, 2022, and April 14, 
2022. 
  You asked the Plan to waive the cost share for the triamcinolone acetonide injection, low osmolar contrast 
material, fluoroscopic guidance, and arthrocentesis. You say that you should not be responsible to pay this. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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% 
coinsurance for a triamcinolone acetonide injection, 20% coinsurance for low osmolar contrast material, a $75 
copayment for fluoroscopic guidance and a $20 copayment for an arthrocentesis.  
 
You have been asked to pay a total of $191.64 for the triamcinolone acetonide injections, low osmolar contrast 
material, fluoroscopic guidance, and arthrocentesis. 
 
Date of Service Service Plan Allowance Cost Per Contract Your Responsibility 
April 13, 2022 Fluoroscopic 
Guidance 
$98.10 $75 $75 
April 13, 2022 Arthrocentesis $59.51 $20 $20 
April 13, 2022 Triamcinolone 
Acetonide Injection 
 
$3.81 
 
20% 
 
$0.76 
April 13, 2022 Low Osmolar Contrast 
Material 
 
$0.30 
 
20% 
 
$0.06 
April 14, 2022 Fluoroscopic 
Guidance 
$98.10 $75 $75 
April 14, 2022 Arthrocentesis $59.51 $20 $20 
April 14, 2022 Triamcinolone 
Acetonide Injection 
 
$3.81 
 
20% 
 
$0.76 
April 14, 2022 Low Osmolar Contrast 
Material 
 
$0.30 
 
20% 
 
$0.06 
Total:    $191.64 
 
The triamcinolone acetonide injection falls within the Medicare Part B prescription drugs benefit category. The 
low osmolar contrast material and fluoroscopic guidance fall within the outpatient diagnostic services benefit 
category. The arthrocentesis falls within the physician 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. Therefore, we decided that the Plan does not have 
to waive the cost share for triamcinolone acetonide injections, low osmolar contrast material, fluoroscopic 
guidance, and arthrocentesis provided on April 13, 2022, and April 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.