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

 
We decided that the Plan has to pay for the liquid biopsy solid tumor panel provided on September 14, 2022. 
 
You asked the Plan to pay for the liquid biopsy solid tumor panel. You say that the enrollee meets criteria for 
this next generation sequencing (NGS) panel. The Plan denied your request. The Plan says that this isn't 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, no medical records were provided in the case file to review. There 
is documentation included in the case file showing the Plan made an effort to obtain this information. 
Therefore, we decided that the Plan has to pay for the liquid biopsy solid tumor panel provided on September 
14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this should be covered. 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 chiropractic care provided on July 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0428, A0425) provided on 
September 26, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that these services were necessary and were 
provided after the enrollee was discharged from one facility and admitted to another. The Plan denied your 
request. The Plan says that the payment for these services is included in the facility payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no documentation to support that these 
services would be classified as inpatient transportation and included in a payment to a facility. The Plan has not 
substantiated their denial or shown that these services would not be separately payable. Therefore, we decided 
that the Plan has to pay for ambulance transportation services (A0428, A0425) provided on September 26, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently at home and not able to get 
anything on your own. You say the home health aide only helped with the shower and you had therapy about a 
month ago. The Plan denied your request. The Plan says your request for an IRF admission does not meet the 
requirements for approval. 
 
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 are at home and able to transfer and walk 50 feet at supervision level. You 
are functioning at a home care level with chronic functional loss. You do not require intensive rehabilitation 
services. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 22, 2022. 
 
You asked the Plan to pay for wound care. You say that you say that the service was rendered due to medical 
necessity and patient care was provided as an urgent request. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hub cap reflectors. 
 
You asked the Plan to pre-approve hub cap reflectors. You say that the enrollee needs these items. The Plan 
denied your request. The Plan says the requested items are not used primarily for medical purposes. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve hub cap reflectors.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 22, 2022, to 
June 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely filed the required 
NOA, so this claim should not be denied. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 22, 2022, to June 1, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft (0627T). 
 
You asked the Plan to pre-approve the allograft. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 allograft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the ViaDisc allograft procedure is experimental. More research is needed to show 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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an allograft (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator. 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had 
ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the ear mold (V5264) purchased on 
December 13, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not covered under the 
supplemental hearing aid policy. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of this item have not been met. Specifically, the item at issue in this case is not a covered benefit 
under the Plans supplemental hearing aid policy. Therefore, we decided that the Plan does not have to issue 
reimbursement for the ear mold (V5264) purchased on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
Please reconsider payment for both us and the patient. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 18, 
2022. 
 
 
You asked the Plan to pay for the pneumatic compression device 
. You say that this device was provided for use during the patient's surgery. The Plan denied your request. The 
Plan says equipment used in a facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care services 
provided on August 28, 2022. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care services. The Plan denied your 
request. The Plan says with the information the Plan has, the Plan 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 hospital inpatient or 
observation care services have been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital inpatient or observation care services provided on August 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 & 99602 billed for date of service 
September 29, 2022. 
 
You asked the Plan to pay for procedure codes 99601 & 99602. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes 99601 & 99602 have a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure codes 99601 & 99602 are not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99601 & 99602 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99601 & 99602 billed for date of service 
September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs this item to try 
to heal bed sores properly. The Plan denied your request. The Plan says this item is not covered under 
Medicare. 
 
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 (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00820) provided from November 9, 
2021, through July 8, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is considered experimental and investigational. 
 
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 anesthesia services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no medical necessity documented to require an anesthesia provider to be 
present for the enrollee's procedures on either service date. There were no intra-operative records or 
documented medications administered by the anesthesia provider/Certified Registered Nurse Anesthetist 
(CRNA) for either date of service. The review has determined that the anesthesia services provided (00820) 
were not reasonable or necessary on November 9, 2021, and July 8, 2022. Of note, it is unclear of how the 
submitted bill/billed units were arrived at for the 12 minute and 9 minute, respectively. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (00820) provided from November 9, 2021, through July 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the denial because 
you are not able to push yourself around with a regular wheelchair due to having a dislocated left shoulder, torn 
rotator cuff and collapsed left shoulder. The Plan denied your request. The Plan says this request cannot be 
covered as the enrollee resides in a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve the Group 2 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV sedation for dental procedures. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says IV sedation is not safe due to your medical conditions. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the documentation provided does 
not meet the criteria for coverage for IV sedation for dental treatment. Due to your comorbidities resulting in 
the procedure being medically unreasonable by increasing the risk of respiratory failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve IV sedation for dental procedures.