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

 
We decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) provided on February 
7, 2022. 
 
You asked the Plan to pay for immunoglobulin light chains testing. You say that you have had these testing 
services provided since January of 2019, and they had always been covered. The Plan denied your request. The 
Plan says that the requested service is considered investigational/experimentational, and previously these 
services were billed with code 83520. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for immunoglobulin light chains testing by a contract provider. The file does not show that 
the Plan provided notice that immunoglobulin light chains testing would not be covered, and the documentation 
does not show that the provider informed you that this service would be billed differently and no longer 
covered. Under Medicare rules, this means immunoglobulin light chains testing is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) 
provided on February 7, 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: Favorable

 
We decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) provided on January 
10, 2022. 
 
You asked the Plan to pay for immunoglobulin light chains testing. You say that you have had these testing 
services provided since January of 2019, and they had always been covered. The Plan denied your request. The 
Plan says that the requested service is considered investigational/experimentational, and previously these 
services were billed with code 83520. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for immunoglobulin light chains testing by a contract provider. The file does not show that 
the Plan provided notice that immunoglobulin light chains testing would not be covered, and the documentation 
does not show that the provider informed you that this service would be billed differently and no longer 
covered. Under Medicare rules, this means immunoglobulin light chains testing is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for immunoglobulin light chains lab testing (83521) 
provided on January 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is needed to increase freedom both indoors 
and in the community. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items are not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided, there is no indication that you have a qualifying diagnosis for the requested group 3 
power wheelchair. The provided records do not document a neurological condition resulting in a level of 
weakness such that her transfers are so limited as to require a group 3 power wheelchair. You are reported to be 
independent with transfers. As you do not meet criteria for the group 3 power wheelchair, the requested 
accessories are not covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
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 the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with AutoEPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that you have 
severe chronic obstructive pulmonary disease, and likely have chronic CO2 retention. You may benefit from 
BiPAP with AVAPS, and may benefit from a BiPAP titration sleep study. However, Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801, 87798, 87481) provided on February 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services were performed by an out-of-network provider. 
Out-of-network care is covered only in certain limited circumstances. The services at issue were not urgent or 
emergent, nor were they pre-approved. 
 
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 lab services (87801, 87798, 87481) provided on 
February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 10, 2022, billed with 
codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are not considered experimental. The Plan denied your request. The Plan says these services were not 
medically necessary and were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 10, 2022, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that medial branch blocks are medically 
necessary. The Plan denied your request. The Plan says medial branch blocks are 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 medial branch blocks. Our reviewer 
says that medial branch blocks are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is significant abnormality seen in the imaging that could be another pain 
generator. The request is deemed not medically reasonable or 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 medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) provided on 
February 4, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that these tests were medically 
necessary and reasonable. The Plan denied your request. The Plan says the panel in question included testing 
for the FANCC gene; therefore, this panel is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests 
that include the FANCC gene. 
 
 
 
 We looked at the file and Medicare rules. The panel provided in this case included the FANCC gene. Based on 
this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis have 
not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence 
analysis (0037U) provided on February 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 enrollee has chronic migraine. She 
has not tried and failed two of the Plan's required drugs from different classes, topiramate, divalproex ,or 
valproic acid; propranolol or metoprolol; and amitriptyline or venlafaxine. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Botox 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 Botox.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician care provided on January 3, 2022. 
 
You asked the Plan to pay for physician care. You say that medically necessary services were provided to the 
enrollee, and you want the Plan to reconsider paying the claim. The Plan denied your request. The Plan says the 
claim was processed and denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that code 31 should be used with services for patients 
in a Part A-covered skilled nursing facility (SNF) stay and POS code 32 should be used with services for 
beneficiaries in a noncovered stay. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physician care have not been met. Specifically, since the enrollee's covered stay ended on 
December 6, 2021, using POS code 31 was not appropriate for this date. Therefore, we decided that the Plan 
does not have to pay for physician care provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic manipulative treatment (98941) 
with the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not medically necessary. Additionally, 
chiropractic treatment is rendered by a network provider. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. Additionally, the Plan contract states that Medicare-
covered services are rendered by a network chiropractor.  
 
 
 
 
 
 
 
 
 
 We reviewed the case file and the Plans rules. Based on this information, we find that the Plans rules for 
coverage of these services have not been met. Specifically, you requested chiropractic care to be rendered by an 
out-of-network provider. The Plan contract states that Medicare-covered services are rendered by a network 
chiropractor. Therefore, we decided that the Plan does not have to pre-approve continued chiropractic 
manipulative treatment (98941) with the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 23, 2021, billed with 
codes 81401, 81403, 81404, 81405, 81406, 81407, 81479 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are not experimental. The Plan denied your request. The Plan says these services are not medically 
necessary in this case and were not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 23, 2021, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81479 and 81408.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve non-sterile gloves. You say that you need these supplies for cleaning and 
changing of diapers. The Plan denied your request. The Plan says non-sterile gloves are not primarily medical 
in nature and are not covered by Medicare. 
 
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 non-sterile gloves.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80061, 36415, 80053) provided on 
April 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network lab services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited 
circumstances. The requested services were not urgent or emergent, they were not pre-approved, and they 
could have been performed by an in-network provider. 
 
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 the general health panel (80061, 36415, 80053) 
provided on April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polymerase chain reaction (PCR) lab testing (87486, 87496, 
87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 87798, U0004 and U0005) provided on December 
7, 2021. 
 
You asked the Plan to pay for PCR testing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the requested PRC viral panel includes more than five pathogens, and 
therefore is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. The requested panel includes more than six pathogens. Based on this 
information, we decided that Medicare rules for coverage of PCR testing have not been met. Therefore, we 
decided that the Plan does not have to pay for polymerase chain reaction (PCR) lab testing (87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 87798, U0004 and U0005) provided on December 
7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 29580-58-RT billed for date of service July 7, 2021. 
 
You asked the Plan to pay for code 29580-58-RT. You say that this is not a duplicate claim. 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 January 27, 2022. 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 code 29580-58-RT have not been met. 
Therefore, we decided that the Plan does not have to pay for code 29580-58-RT billed for date of service July 
7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you have malabsorption 
with pancreatic insufficiency and that without nutrition treatment therapy you can get very sick. The Plan 
denied your request. The Plan says your provider confirmed that you do not have diabetes, kidney disease or a 
renal transplant. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an endoscopic anti-reflux procedure (esophagogastric 
fundoplasty). 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have 
gastroesophageal reflex disease (GERD). You had a hiatal hernia that was one centimeter in 2021. The 
requested procedure is approved by the medical community as a standard treatment option for your condition 
and has been shown in the medical literature to be superior to medication and hold less risk than other surgical 
treatments. The services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve an endoscopic anti-reflux procedure (esophagogastric fundoplasty).  
 
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.