Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for these 
items. 
 
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 contract states that two shoe inserts are covered every 
three years or two inserts every year, depending on the type of insert. However, the Plan contract does not  
clearly disclose information about the type of inserts that are covered every year or every three years. 
Additionally, the Plan has stated that you have exhausted the allowable benefit for these items. However, based 
upon the information provided, the Plan has not substantiated their denial. Therefore, we decided that the Plan 
has to pre-approve foot orthotics (L3020).  
 
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: Favorable

 
We decided that the Plan has to pre-approve Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq 
cm for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records do not indicate that the wound is free of infection currently. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is medically necessary based on the community standard of 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm for the enrollee.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on February 24, 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 that the services were not billed correctly. 
 
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. the Plan references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the testing was performed. The Plan has not provided any Medicare rules or 
documentation to support the services are not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on February 24, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided February 14, 2022. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says medical 
necessity cannot be determined without the requested medical records. 
 
 
 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 targeted genomic sequence analysis, 
51 or greater genes (81455) provided February 14, 2022. have been met. there were no medical notes from the 
doctor included with the appeal. The Plan made multiple attempts to obtain the additional records without 
success. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or 
greater genes (81455) provided February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80051, 82040, 82247, 82310, 82465, 82565, 
82947, 84075, 84155, 84450, 84460 and 84520 billed for date of service January 25, 2022. 
 
You asked the Plan to pay for procedure codes 80051, 82040, 82247, 82310, 82465, 82565, 82947, 84075, 
84155, 84450, 84460 and 84520. You say that these services are supported in the medical record. The Plan 
denied your request. The Plan says the payment for these codes is bundled into payment for other codes billed 
for this date. 
 
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 82465 is a column II code to column I code 80061 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
In addition, we have confirmed that codes 80051, 82040, 82247, 82310, 82565, 82947, 84075, 84155, 84450, 
84460 and 84520 are all column II codes to column I code 80053. These services have 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 codes 80051, 82040, 82247, 
82310, 82465, 82565, 82947, 84075, 84155, 84450, 84460 and 84520 billed for date of service January 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the cost share for oxygen equipment provided from January 30, 2022, to 
March 30, 2022. 
 
You asked the Plan to waive the cost share for oxygen equipment. You say that you should not be responsible 
to pay this. The Plan denied your request. The Plan says that the cost share has been applied correctly. 
 
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 records do not show a breakdown of the deductible to confirm 
you had not met your deductible at the time the January and February claims were processed. In addition, if we 
cannot determine you met your deductible, we also cannot confirm the coinsurance you are being asked to pay 
is correct.  Therefore, we decided that the Plan has to waive the cost share for oxygen equipment provided from 
January 30, 2022, to March 30, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on June 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ECG. You say that it was medically necessary to treat the enrollee and you 
would like the claim processed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 electrocardiogram (ECG) provided on June 14, 
2022, 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 polycarbonate or equal lenses (V2784), photochromatic 
tint (V2744), and anti-reflective coating (V2750) provided on May 25, 2022. 
 
You asked the Plan to pay for the polycarbonate or equal lenses, photochromatic tint, and anti-reflective 
coating. You say that you do not agree with the Plan's denial of coverage for these services. The Plan denied 
your request. The Plan says these services are not covered. 
 
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 they are standard lenses. 
 
 We looked at the file and the Plan's rules. The lenses you purchased are upgraded lenses, and are clearly listed 
as not covered. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate or 
equal lenses, photochromatic tint, and anti-reflective coating have not been met. Therefore, we decided that the 
Plan does not have to pay for the polycarbonate or equal lenses (V2784), photochromatic tint (V2744), and 
anti-reflective coating (V2750) provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for AlloSure genetic testing (81479) provided on September 10, 
2021, and January 24, 2021. You asked the Plan to pay for genetic testing. You say that these services were medically necessary and are 
payable by Medicare. The Plan denied your request. The Plan says these services were not pre-approved and 
sufficient medical records were not provided to review this claim. 
 
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. The rules say that diagnostic tests which are not ordered by the phyisican who 
is treating the beneficiary are not reasonable and necessary. 
 
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 genetic testing have been met. 
Specifically, a signed and dated order from the enrollees treating physician was not included in the submitted 
records. In addition, no progress notes or records from the treating provider were included to show intention to 
provide this test and support medical necessity. Therefore, we decided that the Plan does not have to pay for 
AlloSure genetic testing (81479) provided on September 10, 2021, and January 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided December 22, 2021. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel testing provided December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service November 
10, 2021. 
 
You asked the Plan to pay for procedure code 70551. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
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 on December 8, 2021. 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 procedure code 70551 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70551 billed for date of service 
November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker, folding, wheeled, adjustable or fixed height 
(E0143) and cane, includes canes of all materials, adjustable or fixed, with tip (E0100) purchased January 23, 
2022 to February 24, 2022 from a non-Medicare certified provider. 
 
You asked the Plan to pay for the walker and cane. You say that the supply company that is close to your does 
not take the Plan and you would have to drive 30 miles one way to get to the closest medical supply store. The 
Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, 
you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker, folding, wheeled, adjustable 
or fixed height (E0143) and cane, includes canes of all materials, adjustable or fixed, with tip (E0100) 
purchased January 23, 2022 to February 24, 2022 from a non-Medicare certified provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43239). 
 
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says this service does not 
meet medical necessity. 
 
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 an EGD. Our reviewer says that the 
requested EGD is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you meet none of the high-risk personal history, and are not taking anticoagulants nor long-term non-
steroidal anti-inflammatory drug (NSAID) therapy. Our reviewer found that the surveillance criteria are not 
met as provided to warrant a repeat EGD at this time to reevaluate your history of erosive gastropathy. Our 
physician reviewer also found that an EGD is not clinically needed to assess Helicobacter pylori eradication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric upper extremity prosthesis. 
 
You asked the Plan to pre-approve a myoelectric upper extremity prosthesis. You say that the requested 
myoelectric upper extremity prosthesis is medically necessary. The Plan denied your request. The Plan says the 
requested myoelectric upper extremity prosthesis 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 a myoelectric upper extremity 
prosthesis. Our reviewer says that the requested myoelectric upper extremity prosthesis is not medically 
necessary. Our physician reviewer found the documentation does not support that a standard body-powered 
prosthetic device cannot be used or is insufficient to meet the functional goals and needs of the enrollee. The 
documentation does not support that a myoelectric device is likely to help the enrollee regain or maintain 
function better than a standard body-powered prosthetic device. A Systematic Literature Review in the Journal 
of Prosthetics and Orthotics in 2017 indicates conflicting evidence has been found in terms of the relative 
functional performance of body-powered and myoelectric prostheses. Body-powered prostheses have been 
shown to have advantages in durability, training time, frequency of adjustment, maintenance, and feedback but 
could still benefit from improvements of control. Myoelectric prostheses improve cosmesis and phantom-limb pain and are more accepted for light-intensity work. Currently, evidence is insufficient to conclude that either 
system provides a significant general advantage. 
 
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 myoelectric upper extremity prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a myoelectric upper extremity prosthesis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Triage testing (81479) provided February 22, 
2022. 
 
You asked the Plan to pay for the Cxbladder Triage testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is not covered because it was done for screening 
purposes.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Cxbladder Triage testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Cxbladder Triage testing (81479) provided February 22, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a bunionectomy. 
 
You asked the Plan to pre-approve a bunionectomy. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a bunionectomy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a bunionectomy is considered standard of care for treatment of a recalcitrant painful bunion 
deformity. It appears that you meet the Medicare criteria for coverage of a bunionectomy. Therefore, the 
requested bunionectomy at issue in this case is medically reasonable and 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 a bunionectomy have been met. Therefore, we decided that the Plan has to pre-
approve a bunionectomy.  
 
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.