Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of soft tissue of the 
neck with and without contrast (70492). 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that the CT scan is medically necessary 
because the enrollee has persistent pain which has only somewhat improved with prescription medication. The 
Plan denied your request. The Plan says the rules for coverage of a CT scan of the neck have not been met. The 
Plan says a detailed history or physical exam that shows why the study is needed has not been provided. The 
Plan cannot determine if the service is medically reasonable and necessary in the absence of evidence.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary and meet the coverage indications for certain conditions or symptoms that make the use of 
an MRI unsuitable.  
 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 CT scan of the neck. Our reviewer 
says that the requested service is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has had three prior tele-med visits regarding the symptoms at issue but has not been seen for an in-
person consultation. Therefore, there are no records of a physical exam to determine medical necessity.  
 
Our physician reviewer also found the enrollee has a history of hypothyroidism and sinusitis. A medical note in 
the file from May 2022 states that the enrollees sinusitis and neck pain is improving. In the absence of a 
physical exam, our physician reviewer says there are no red flags indicating a CT scan is needed. Furthermore, 
no follow-up examination has occurred since the enrollees symptoms were noted to be improving. No reason 
has been given for medical necessity of the requested CT scan. 
 
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 CT scan of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of soft tissue of the neck with and without 
contrast (70492).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura 1.5% cream. 
 
You asked the Plan to pre-approve Opzelura. You say that Opzelura is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura 1.5% cream.  
 
 
 
 
 Benefits for Opzelura may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for Outpatient exam of visual field with 
extended testing on January 25, 2022. 
 
You asked the Plan to waive the deductible for vision services. You say that the out-of-pocket amount is too 
high. The Plan denied your request. The Plan says The deductible applies to established patient office or other 
outpatient visit, 30-39 minutes and exam of visual field with extended testing. Outpatient physician services 
provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries of the 
eye, including diagnosis or treatment for age-related macular degeneration or cataracts. Original Medicare 
doesnt cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
 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 
$126.05 deductible for covered medical services. The provider billed the plan in the amount of $125.00 and the 
allowed amount is $122.77. The provider also billed the plan in the amount of $100.00 and the allowed is 
$59.03. The plan paid $55.75 with the remaining amount of $3.29. The total allowed amount is $126.05.  
 
You have been asked to pay a $126.05 deductible for vision services. Vision services visits fall within the 
Vision 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 deductible for Outpatient exam of visual 
field with extended testing on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair 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 there is no medical need for a group 3 power wheelchair with the requested power 
options. 
 
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not meet criteria for the multiple power options (power tilt/recline and elevating leg rests). She has no history 
of pressure sores, does not utilize intermittent catheterization for bladder management or have increased muscle 
tone or spasticity. The patient does not have a musculoskeletal condition or the presence of a cast or brace 
which prevents 90 degree flexion at the knee or have significant edema of the lower extremities that requires 
an elevating leg rest. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carrying case for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a carrying case for a CPAP. You say that you need a case so that your 
CPAP does not get smashed. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
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 a carrying case for a continuous positive airway pressure 
(CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cyclosporine ophthalmic solution. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve cyclosporine ophthalmic 
solution.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit specimen collection 
rendered on December 29, 2021. 
 
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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. The file shows that procedure code C9803 was billed with a home 
health type of bill. This is the incorrect type of bill for this code. 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 hospital outpatient clinic visit specimen collection rendered on December 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 7, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are not able to get 
around due to your disability, so you need the ambulance. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $250 
copayment for each one-way Medicare-covered ground ambulance trip. 
.  
 
 
 
 You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on January 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA and RNA analysis (81445) provided October 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this test should be considered a medical 
necessity and was requested by the referring physician to aid in the clinical management of this enrollee. The 
Plan denied your request. The Plan says that CPT code 81445 has not met associated diagnosis code. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is an 84-year-old man with a diagnosis of nontoxic single thyroid nodule. An 
ultrasound-guided thyroid solid aspirate right isthmus fine needle aspiration collected on 9/28/21 demonstrated 
the presence of atypical cells. The morphologic findings are suspicious for papillary thyroid carcinoma. A 
cytology diagnosis of "Atypical/FLUS (III)" is noted. The medical records provided meets the medically 
necessary requirements listed in the LCD for Medicare coverage. LCD L35396 states that ThyGeNEXT will be 
considered reasonable and necessary for patients with an indeterminate pathology on fine needle aspiration. 
 
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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA and 
RNA analysis (81445) provided October 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 26, 2021, billed with 
codes 81304, 81408, 81405, and 81406. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare 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 is 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 have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 26, 
2021, billed with codes 81304, 81408, 81405, and 81406.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Intraosseous Nerve Ablation System. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a reasonable treatment of the 
enrollee's condition. The Plan denied your request. The Plan says this procedure remains experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to the Food and Drug Administration (FDA) Indications for Use, the 
Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency 
generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low 
back pain of at least six months duration that has not responded to at least six months of conservative care, and 
is also accompanied by features consistent with Type 1 or Type 2 Modic changes. 
 
This 80-year-old female was being treated for spondylosis of the lumbar spine without myelopathy or 
radiculopathy. She presented with low back and buttock pain. Her pain has been present for many years and has worsened over the past few months. The pain is increased with walking, standing, bending, twisting, 
prolonged sitting, and laying down. At its worst, it is 101/10 on the pain scale. 
 
However, the non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, along 
with the diminished and painful spinal motion (in all directions) and intact neurologic exam were/are all non-
specific to any pathologic entities. In this case, there were/are multiple plausible pathologic sources of 
significant pain generation. Overall, documentation was/is lacking regarding reasonably detailed and/or 
evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of 
the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the request for Intracept intraosseous nerve ablation at L5 and 
S1 is 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept Intraosseous Nerve Ablation System.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on February 3, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you believe the charge should be 
covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $30 
copayment for each Medicare-covered x-ray.  
 
You have been asked to pay $30 copayment for an x-ray.  X-rays fall within the Outpatient diagnostic tests 
and therapeutic services and supplies 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 
an x-ray provided on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on January 14, 2022, 
billed with code 85060. 
 
You asked the Plan to pay for the blood smear interpretation. You say that this was provided in the appropriate 
place of service and should be paid. The Plan denied your request. The Plan says this code is not payable in the 
outpatient hospital place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 85060 has a Pro/Tech flag of 8. This indicator identifies the professional component of clinical 
laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear 
for hospital inpatient. No payment is recognized for CPT codes 88141, 85060 or HCPCS code P3001-26 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of the blood smear interpretation have not been met. Therefore, we decided that the Plan 
does not have to pay for the blood smear interpretation provided on January 14, 2022, billed with code 85060.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic orthotics (A5500, A5512) provided on February 28, 
2022. 
 
You asked the Plan to pay for diabetic orthotics. You say that the items at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the items at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for diabetic orthotics (A5500, A5512) provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for acupuncture visits provided from 
December 14, 2021, to December 23, 2021 . 
 
You asked the Plan to waive the coinsurance for acupuncture visits. You say that you expected the plan to pay 
more money. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 40% 
coinsurance for out of network visits in an acupuncture specialists office.  
 
You have been asked to pay $69.60 which is 40% of the allowed amount for acupuncture visits. The allowed 
amount is $174.05 (20% x $174.05=$69.60). Acupuncture visits fall within the Acupuncture for chronic low 
back pain 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 coinsurance for acupuncture visits 
provided from December 14, 2021, to December 23, 2021 .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen handling services provided on November 18, 
2021, billed with code 99000. 
 
You asked the Plan to pay for the specimen handling services. You say that this claim should be paid. The Plan 
denied your request. The Plan says code 99000 is not separately payable. 
 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 99000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the specimen handling services have not been met. Therefore, we decided that the Plan does not have to pay 
for the specimen handling services provided on November 18, 2021, billed with code 99000.