Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided from 
June 28, 2022, to July 12, 2022. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the Plan covered chiropractic 
services with this same provider rendered on January 25, 2022. The Plan denied your request. The Plan says 
Medicare only pays for active/corrective acute or chronic subluxation. Maintenance therapy services are not 
eligible for payment per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the file, the Plans rules and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided that the 
Plan does not have to pay for chiropractic manipulative treatment provided from June 28, 2022, to  
July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior cervical decompression and fusion (ACDF) 
surgery. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the most recent magnetic resonance 
imaging (MRI) of your neck spine does not show spinal cord compression. There is also no recent MRI of the 
lower (lumbar) spine. The requested ACDF surgery is therefore not indicated and not 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 anterior cervical decompression and fusion (ACDF) surgery.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Radium ra-223 Dichloride (A9606) provided on April 8, 2021. 
 
You asked the Plan to pay for the Radium ra-223 Dichloride. You say that you would like this claim to be 
reprocessed for additional payment. The Plan denied your request. The Plan says that this denial is due to a lack 
of authorization being obtained prior to rendering services. 
 
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. We find that the Plan's exception list is not based on Medicare guidelines. This 
drug has not been denied based on any Medicare-approved guidelines. Consequently, the Plan has not 
substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the 
Radium ra-223 Dichloride (A9606) provided on April 8, 2021.  
 
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 procedure code 93976 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 93976. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for 
code 76857. 
 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 93976 
is a column II code to column I code 76857. 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 93976 billed for date of service August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 27, 2022. 
 
You asked the Plan to pay for the office visit. You say that the provider did nothing for you except touch a 
feather to the back of your hand and had you look up and down and referred you to a neurosurgeon to be tested 
and then to come back for treatment. The Plan denied your request. The Plan says services other than 
manipulation of the spine are not covered by the Plan when billed by a chiropractor. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for an office visit provided on  
August 18, 2022. 
 
You asked the Plan to pay an additional amount for the office visit. You say that the member should only be 
responsible for a $30 copayment. 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. Your 
contract with the Plan says that there is $750 deductible which applies to covered medical services.  
 
The item or service you asked the Plan to pay an additional amount for falls within the what is your plan 
deductible benefit category for covered medical services. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to covered medical services. This cost 
sharing is a contractual obligation that had not been met at the time the office visit was received on  
August 18, 2022. Therefore, we decided that the Plan does not have to pay an additional amount for an office 
visit provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided by an out-of-network 
provider. 
 
You asked the Plan to pay for the annual wellness visit provided by an out-of-network provider. You say that 
this services is a covered benefit. The Plan denied your request. The Plan says out-of-network services are 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an annual wellness visit provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this is a separately billable procedure. The 
Plan denied your request. The Plan says there are no modifiers allowed with this code pair. 
 
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 93042 is a column II code to column I code 99291 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, the Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93042 
billed for date of service January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sclerotherapy.  
You asked the Plan to pre-approve a sclerotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sclerotherapy is covered when a 3-month trial of 
conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance 
of prolonged immobility where appropriate, has failed. 
 
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 sclerotherapy. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member has not had a 3-month trial of 
conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance 
of prolonged immobility where appropriate, has failed. 
 
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 sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sclerotherapy.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that the request is not medically necessary. 
 
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 a continuation of SNF care. Our 
reviewer says that the requested SNF care is considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that you continue to have functional impairments although improving 
with skilled therapy still requiring max assist with self-care. There is no specific recommendation given in 
regard to skilled nursing frequency but evaluating therapists recommend continued daily skilled therapy thus 
from a practical standpoint, daily skilled services in a skilled nursing facility are 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a continuation 
of SNF care.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device(s) 
services provided on January 17, 2022. 
 
You asked the Plan to pay for the insertion of intervertebral biomechanical device(s) services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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, the CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical 
device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, 
flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in 
conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 22854 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with 
integral anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral 
corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody 
arthrodesis, for each contiguous defect (listed separately in addition to code for primary procedure); therefore, 
this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
insertion of intervertebral biomechanical device(s) services have not been met. Therefore, we decided that the 
Plan does not have to pay for the insertion of intervertebral biomechanical device(s) services provided on 
January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
July 8, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and was provided 
for a covered indication. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. In addition, this claim was submitted with an incorrect 
place of service code. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also 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. Review of the claim does not show that the required unique identifier 
was reported. In addition, this claim was billed with the laboratory POS code, but the records do not support 
that the sample was taken in a laboratory setting.  Based on this information, we decided that Medicare rules 
for coverage of F1CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne CDx (F1CDx) (0037U) testing provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81240, 81291, 81306, 8328, 81355, 81335, 81401, 
0031U, 0032U, 0033U and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. In addition, the criteria for coverage of this test are not met. 
 
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 
June 9, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81240, 81291, 81306, 
8328, 81355, 81335, 81401, 0031U, 0032U, 0033U and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 15, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the application of a skin substitute (Q4101, 15275). 
 
You asked the Plan to pre-approve the application of a skin substitute. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has 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 the application of a skin substitute. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the skin substitute graft will allow the enrollee to avoid a major surgical procedure. 
 
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 application of a skin substitute have been met. Therefore, we decided that 
the Plan has to pre-approve the application of a skin substitute (Q4101, 15275).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), and progressive lenses (V2781) 
received on June 28, 2022. 
 
You asked the Plan to pay for deluxe frames and progressive lenses. You say that you did not know that you 
had to use an in-network provider. The Plan denied your request. The Plan says these services are not covered 
when received out-of-network.  
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 you utilize an in-network provider. 
 
We looked at the file and the Plan's rules. The items were received out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of deluxe frames and progressive lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), and progressive lenses 
(V2781) received on June 28, 2022.
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 inpatient rehab is physically and medically necessary 
for the enrollee to return home to their maximum level of functioning with a decreased risk for readmission. 
The Plan denied your request. The Plan says the IRF services you are requesting do 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inogen Portable Oxygen Concentrator, to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an Inogen Portable Oxygen Concentrator. You say that the item should be 
covered. The Plan denied your request. The Plan says there are in-network providers that offer this item. 
 
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 
an Inogen Portable Oxygen Concentrator, to be provided by an out-of-network (OON) provider.