Persius/hicric huggingface dataset:
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 a home ventilator. You say that the enrollee's muscular dystrophy impacts 
her ability to breathe. The Plan denied your request. The Plan says the requested pressure settings can be met 
with the use of a BiPAP device. 
 
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 a home ventilator. Our physician 
reviewer found that the enrollee has a diagnosis of COPD, muscular dystrophy (MD), heart failure with 
preserved ejection fraction (HFpEF), and cerebral palsy. There are no pulmonary function data to confirm 
either obstructive or restrictive lung disease or assess severity. The diagnosis of MD is reported by the enrollee 
and carried forward in the record, but there is no data to confirm the diagnosis or the type of MD, and she is not 
followed by a neurologist.   There is no arterial blood gas to confirm carbon dioxide retention. The recent hospitalizations appear to be 
related primarily to exacerbation of HFpEF. The stated plan for ventilator use during the day as needed, and not 
during sleep, do not represent standard of care and is unlikely to be beneficial. Therefore, a home ventilator is 
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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema therapy. 
 
You asked the Plan to pre-approve lymphedema therapy. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that lymphedema treatment will be covered when 
there is a diagnosis of lymphedema (not tissue edema due to other etiologies e.g., chronic venous insufficiency, 
congestive heart failure, acute infection). 
 
We looked at the file and Medicare rules. In this case, the medical records do not support a definitive diagnosis 
of lymphedema. Based on this information, we decided that Medicare rules for coverage of lymphedema 
therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve lymphedema 
therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on December 7, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99153 is not supported. Specifically, there is an associated code that describes the 
professional component. 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 pay for the sedation services provided 
on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) and emergency 
anesthesia (99140) provided on November 20, 2021. 
 
  You asked the Plan to pay for the special anesthesia service (99100) and emergency anesthesia (99140). You 
say that guidelines allow CPT code 99100 to be billed separately when the patient is under one year of age or 
over 70 years of age. You say that CPT code 99100 and 99140 should be reimbursed as one additional 
anesthesia unit. The Plan denied your request. The Plan says procedure code 00811 has been paid. The Plan 
also says procedure codes 99100 and 99140 remain denied as bundled services are not eligible for separate 
reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT code 99100 and 99140 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the special anesthesia service (99100) and emergency anesthesia (99140) have 
not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service 
(99100) and emergency anesthesia (99140) provided on November 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
September 3, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you asked the Plan for 
the cost out of pocket. You say the Plan stated as long as nothing was found it would be coded as preventative. 
The Plan denied your request. The Plan says you have been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
in-network copayment for each Medicare-covered service in an emergency department or outpatient clinic, 
such as observation services or outpatient surgery.  
 
 
 
 You have been asked to pay a $290 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a diagnostic colonoscopy provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint ablation procedure (64635, 64636). 
 
You asked the Plan to pre-approve the facet joint ablation procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when the patient 
has had at least two (2) medically reasonable and necessary diagnostic medial branch blocks, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
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 facet joint ablation procedure. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found the records show 
that the previous medial branch blocks only provided 50% pain relief. 
 
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 facet joint ablation procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a facet joint ablation procedure (64635, 64636).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injections (J7321). 
 
You asked the Plan to pre-approve Supartz injections. You say that the enrollee had their last injection more 
than 1 year ago. You say that the enrollee cannot take NSAIDs due to chronic kidney disease 3. You also say 
that the enrollee received steroid knee injections on March 24, 2022. The Plan denied your request. The Plan 
says the enrollee has not tried and failed the preferred drug, Euflexxa. 
 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 Supartz injections. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided documentaiton does 
not indicate that the enrollee has tried and failed the preferred drug, Euflexxa. The reviewer found that the 
documentation does not indicate that the plan's required drug would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Supartz injections (J7321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee would like to continue 
physical therapy. The Plan denied your request. The Plan says the clinical notes do not verify progressive 
functional improvement in a reasonable period of time. The Plan also says that the clinical documentation does 
not show that the unique skills of a physical therapist are required to safely and effectively provide treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. Our reviewer 
found that the patient has had prior therapy and the documentation does not reveal that the patient requires the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our 
physician reviewer also found that the requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018) and monthly supplies for use of device coded at K1018 (K1019). 
 
You asked the Plan to pre-approve a Cala Trio therapy system. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 Cala Trio therapy system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the studies that have been done of the device are largely preliminary in 
nature. While there are no safety or adverse effects observed during studies, the utility and efficacy of this 
technology otherwise remains to be determined. More specifically, study is needed in order to determine the 
efficacy of therapy when compared to other interventions/medications for essential tremor. 
 
 
 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 Cala Trio therapy system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist 
(K1018) and monthly supplies for use of device coded at K1018 (K1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy, rigid or flexible, including fluoroscopic 
guidance, when performed (31624) 
 
You asked the Plan to pay for the procedure. You say that your provider is credentialed and licensed as a 
medical doctor of anesthesiology. Your provider performed this bronchoscope via an endotracheal tube and this 
procedure should be payable to an anesthesiologist. The Plan denied your request. The Plan says this service 
contains non-anesthesia services submitted by an anesthesiologist. Separately billed services/tests have been 
bundled as they are considered components of the same procedure. 
 
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 31624 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed. 
 
We find that CPT code 31624 is not supported in the medical record. Specifically, this service was a non-anesthesia service submitted by a provider with an anesthesiology specialty. Per the American Society of 
Anesthesiologists Crosswalk table, the service billed would not be performed by an anesthesiologist. Based on 
this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, 
we decided that the Plan does not have to pay for the bronchoscopy, rigid or flexible, including fluoroscopic 
guidance, when performed (31624)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 1, 2020. 
 
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 procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
15 drug classes were tested. 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 pay for the drug testing 
rendered on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81408, 81162, 
81321 and 81407) provided on October 4, 2021. 
 
You asked the Plan to pay for the molecular pathology testing. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81408, 81162, 
81321 and 81407) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital laboratory services and the office visit 
provided on February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital laboratory services the office visit. You say that the 
enrollee presented for a follow-up visit and the physician ordered laboratory work. The Plan denied your 
request. The Plan says no prior authorization was obtained. 
 
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 
outpatient hospital laboratory services and the office visit. We found no exception that would require the Plan 
to pay for outpatient hospital laboratory services and the office visit. The record shows CPT code 36415 was 
billed which means the provider had the opportunity to confirm insurance coverage and authorization. 
Therefore, we decided that the Plan does not have to pay for outpatient hospital laboratory services and the 
office visit provided on February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64634) provided on December 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 services. Our reviewer says that the use of code 64634 is 
not supported by the records provided. Our reviewer found that the provider reported 2 units for destruction by 
neurolytic agent of medial branch nerves at C4, C5 and C6. Per CMS, codes 64633, 64634, 64635, 64636 are 
reported per joint, not per nerve.  Although two nerves innervate each facet joint, only one unit per code may 
be reported for each joint denervated, regardless of the number of nerves treated. 
 
We looked at this coder'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 pay for the services (64634) provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided from November 24, 
2021, through December 8, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that you thought these services were covered 
under your contract with the Plan. The Plan denied your request. The Plan says these services are not covered 
when performed 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 services at issue were not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for therapeutic exercises (97110) provided from November 24, 2021, through 
December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on July 9, 2021. 
 
You asked the Plan to pay for an X-ray of the chest. You say that the claim at issue was denied as a duplicate in 
error. The Plan denied your request. The Plan says rules for payment have not been met because the claim at 
issue is a duplicate of a prior claim that was processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an X-ray of the chest have not been met. Specifically, the Plan has documented that the claim at 
issue is a duplicate of a prior claim that has been processed and paid.  The available medical records do not support that more than one instance of an X-ray of the chest was provided 
on the date of service. Therefore, we decided that the Plan does not have to pay for an X-ray of the chest 
(71045) provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the spherocylinder, trifocal, plano to 
plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens (V2303), progressive lens, per lens (V2781) and anti-
reflective coating (V2750) provided January 14, 2022. 
 
You asked the Plan to provide additional payment for the spherocylinder, trifocal, progressive lenses with anti-
reflective coating. You say that you feel you have already paid your portion of the bill. The Plan denied your 
request. The Plan says you have exceeded your vision allowance and no further payment is due. 
 
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 up to a total of $200 every calendar year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your full $200 vision 
benefit was applied to your eyeglasses purchased January 14, 2022. You have been asked to pay the amount 
above this $200 benefit. Therefore, we decided that the Plan does not have to provide additional payment for 
the spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens (V2303), 
progressive lens, per lens (V2781) and anti-reflective coating (V2750) provided January 14, 2022.