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

 
We decided that the Plan has to pre-approve 180 additional colostomy bags (A4416). 
 
You asked the Plan to pre-approve the additional colostomy bags. You say that the additional ostomy bags are 
medically necessary. The Plan denied your request. The Plan says that the usual allowable maximum amount 
has already been approved. Additional bags are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that explanation for use of a greater quantity of supplies 
than the amounts listed must be clearly documented in the beneficiarys medical record. 
 
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 additional colostomy bags. Our 
reviewer says that the additional ostomy bags are medically necessary. Our physician reviewer found review 
indicates that the enrollee has a history of colon cancer, status post hemicolectomy with colostomy in 1995. 
The provider notes that enrollee historically produces large amount of liquid stool requiring him to change his 
colostomy bag 3 to 5 times a day. The additional bags are medically necessary based on the provided records. 
 
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 additional colostomy bags have been met. Therefore, we decided that the 
Plan has to pre-approve 180 additional colostomy bags (A4416).  
 
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 Covid-19 test provided on December 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that your wife had symptoms and you went to get 
tested. The Plan denied your request. The Plan says the test is not covered by your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the 
Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in 
this case.  
 
We looked at the file and the rules. Although your plan offers an over-the-counter benefit, the test at issue is 
not among the items covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the Covid-19 test provided on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to 
compression and other maneuvers; complete bilateral study (97930) provided on January 17, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
 
 The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are considered 
medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially 
impact the clinical management of the patient. 
 
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 duplex scan. Our reviewer says that the 
duplex scan is not medically necessary. Our physician reviewer found the provided documentation indicates 
that the exam on the date of service in this case had a history/indication of rib fractures. The reviewer found 
that there were no other symptom or history was included. The reviewer also found that history rib fractures is 
not a valid reason for bilateral lower extremity ultrasound. Therefore, the reviewer found that the service was 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan of extremity veins including responses to compression and other maneuvers; 
complete bilateral study (97930) provided on January 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the services (70450) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 93010 is a column II code to column I code 92978. 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 the services provided 
on December 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine/Prilocaine cream. 
 
You asked the Plan to pre-approve Lidocaine/Prilocaine cream. You say that the requested cream is to be used 
for anesthesia purposes prior to her chemotherapy treatment of breast cancer. The Plan denied your request. 
The Plan says the requested drug does not fall under Part B coverage. The Plan says that the enrollee does not 
have pharmacy benefits administered under this contract. 
 
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 Lidocaine/Prilocaine cream.  
 Benefits for Lidocaine/Prilocaine cream 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed. 
 
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. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 support that you require 
frequent changes in position and multiple positions that would not be available with a regular bed due to pain 
and congestive heart failure. You also have documented difficulty with bed mobility and transfers. From a 
practical standpoint, a semi-electric hospital bed is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve a semi-electric hospital bed.  
 
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 the eyeglasses (V2020, V2745, V2750, V2781, V2784) 
provided on January 21, 2022. 
 You asked the Plan to pay for the eyeglasses. You say that you went in for a yearly eye exam and were told you 
needed a stronger prescription. The Plan denied your request. The Plan says your benefit covers one set of 
eyewear every two years. You previously received eyeglasses on January 3, 2021, which were covered by the 
Plan at that time. 
 
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 once every two years. 
 
We looked at the file and the Plan's rules. The record shows that you received eyeglasses within the last two 
years which were covered by the Plan. This means your benefit was exhausted on the date in question. Based 
on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2745, V2750, V2781, 
V2784) provided on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Ultrasound on October 27, 2021. 
 
You asked the Plan to waive the copayment for an Ultrasound. You say that you would like to appeal the cost 
share. 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 a $60 
copayment for An Ultrasound.  
 
You have been asked to pay a $60 copayment for an Ultrasound. An Ultrasound falls 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 Ultrasound on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on February 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the code. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status. 
 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that 
the services at issue required the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the sedation services provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman interspinous fusion device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
service is considered experimental and investigational. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis of the lumbar region with neurogenic 
claudication. He presented with low back pain. He did not get as much relief from the facet injections as he had 
hoped. He still has back and lower extremity pains. Current evidence-based medical guideline and peer-
reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of 
lumbar fusion. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition as discussed above.  
 
 This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal 
stenosis (including the planned level of implantation L5-S1.) FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis (which have not been adequately addressed in the medical records.) There 
is no discussion of scoliosis of the lumbar spine. There is no discussion indicating that a DEXA scan has 
demonstrated the lack of significant osteoporosis in this patient. In addition, fusion indications within 
guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met 
in this case. There are also multiple alternate pain generators plausibly significantly contributing to the clinical 
condition that have not been fully documented as having been excluded and/or ruled out. 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 Minuteman interspinous fusion device at L5-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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman interspinous fusion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on February 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that your physicians are hospital based and your 
providers rely on the facility to obtain proper authorization. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
 
 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 initial observation care (99220) provided on 
February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from this level of care. The 
Plan denied your request. The Plan says that the services the enrollee needs can be provided safely in other 
settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on December 21, 
2021, billed with code 85060. 
 
You asked the Plan to pay for the blood smear interpretation. You say that this is a separately payable service. 
The Plan denied your request. The Plan says this is not paid to a physician in the outpatient/non-hospital 
settings. 
 
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, which 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.  
 
This service was provided to a hospital outpatient. 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 
December 21, 2021, billed with code 85060.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) panel provided on October 12, 2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this testing is covered by Medicare and is 
medically necessary. The Plan denied your request. The Plan says that this panel includes testing of the 
FANCC gene, which is statutorily excluded per Local Coverage Article A53628. 
 
We reviewed the Plans denial rationale and find it is not compelling. Though this panel includes the FANCC 
gene, which is noncovered per the cited local contractor rules, this is an FDA-approved NGS test which is 
nationally covered. The local contractors rule cannot supersede the NCD cited in this decision. As this testing 
can be covered, we find that the plan-directed care rules apply.  
 
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. 
 
The enrollee was referred for the F1CDx panel by a contract provider. The file does not show that the plan 
provided notice that the F1CDx panel would not be covered. Under Medicare rules, this means the F1CDx 
panel is considered approved by the plan. Therefore, we decided that the Plan has to pay for the FoundationOne 
CDx (F1CDx) panel provided on October 12, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide 128 additional routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that this transportation is necessary for you to 
get to your appointments. The Plan denied your request. The Plan says your benefit covers a maximum of 60 
trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide 128 additional routine transportation trips for 2022.