Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 6, 2022, 
through March 7, 2022. 
 
You asked the Plan to pay for home health services. You say that you have been reimbursed for multiple clients 
where only a RAP was sent, and you were never notified that an NOA was a requirement. You say that services 
were provided in good faith with the expectation of being reimbursed. The Plan denied your request. The Plan 
says a valid NOA is required to process a claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, a valid NOA was not submitted. Therefore, 
we decided that the Plan does not have to pay for home health services provided from February 6, 2022, 
through March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace by Myomo (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the device has been embraced 
by clinicians nationwide and recommend in AHA guidelines for stroke rehabilitation as the only available 
treatment for individuals with moderate to severe upper limb paresis. The Plan denied your request. The Plan 
says experimental and investigational procedures are not covered by Medicare. 
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. Although records from the device manufacturer/vendor argue medical necessity of the 
requested device, no records from the enrollee's actual treating provider clarify why the requested device is the 
most appropriate treatment for the enrollee's condition. In addition, provided records report right upper 
extremity spasticity which may be a contraindication to use of the device. 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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace by Myomo (L8702).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on February 
16, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare and was reported correctly. The Plan denied your request. The Plan says that there is a Local 
Coverage Determination (LCD) that indicates that any panel that tests for the FANCC gene is non-covered. 
Since this panel includes that, the denial is correct. In addition, the Plan says that this test was billed with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. In addition, the rules say 
that while generally laboratory claims should be submitted with the date of service of the specimen collection, 
there are three exceptions to this rule. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. Although there is a Local Coverage 
Determination (LCD) which states that one of the genes in this panel is not covered, this LCD inadvertently 
conflicts with the higher authority of the National Coverage Determination in this case and is overruled. In 
addition, the specimen in this case was collected on July 12, 2018, as part of an outpatient endoscopy or biopsy. It would have been inappropriate to have collected this sample outside of this procedure and the results of this 
testing did not impact the hospital care provided at that time. This means that one of the exceptions to the 
general rule have been met, and the correct date of service for this claim would be the date of testing: February 
16, 2022. Therefore, we decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) 
provided on February 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), anti-reflective coating (V2750), 
progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on January 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the glasses. The Plan denied your request. The Plan says the treating provider is 
OON with the Plan, and there is no coverage when services are rendered by a non-participating provider. 
 
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 they are rendered by a Plan-approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows you received these glasses from an OON provider. 
Based on this information, we decided that the Plan's rules for coverage of the glasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames (V2020), anti-reflective coating 
(V2750), progressive lens (V2781), and polycarbonate or equal lens (V2784) provided on January 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision-benign lesions procedures on the skin provided on 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for excision-benign lesions procedures on the skin. You say that you are appealing 
the claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advanced. 
  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 excision-benign lesions procedures on the skin 
provided on April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules 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. The claim was billed with the laboratory POS code. 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 the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that chart notes were submitted to show medical 
necessity. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage 
for such a device is available upon request. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
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 (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin (E0784). 
 
You asked the Plan to pre-approve an external ambulatory infusion pump. You say that you depend on insulin 
4 times a day for 5 years. The requested insulin pump and sensor are necessary. The Plan denied your request. 
The Plan says you do not meet Medicare's coverage criteria for an insulin infusion pump. The medical record 
shows that your C peptide levels do not meet Medicare's coverage 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 an external ambulatory infusion pump. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the review indicates that the usual parameters established for the 
External Insulin Infusion Pump are presentation of a C-peptide level less than or equal to 110% of the lowest 
level of normal parameters and glucose levels equal to or less than 225mg/dl. Both results are evaluated on 
03/30/2022 and the C-peptide levels are 1.37 ng/dl (parameters .90-7.10), and the fasting glucose levels are 225 
mg/dl, not complying with the previously described parameters. The results of the C-peptide are not within the 
parameters established in the definition of insulinopenia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external ambulatory infusion pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin (E0784).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation provided on February 18, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency transportation. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 non-emergency transportation provided on 
February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) received on April 27, 2022. 
 
You asked the Plan to pay for anti-reflective coating. You say that the anti-reflective coating is necessary, and 
you want the Plan to cover it. The Plan denied your request. The Plan says the item at issue is not a covered 
benefit. 
 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. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of anti-reflective coating have not been met. Specifically, the anti-reflective coating is not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for anti-reflective coating (V2750) received 
on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. 
 The Plan denied your request. The Plan says criteria for admission to an LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically, but still requires care at an acute 
care hospital. The enrollee can receive further care at the current acute care hospital or a lower level of care 
when deemed appropriate.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 22, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that the services provided were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network, and it was determined these services can be 
received in-network. 
 
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 an x-ray provided on March 22, 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 procedure code 99100 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the use of the requested drug is not supported 
because the records do not show that the enrollee's hemoglobin (Hgb) level is less than 10 grams per deciliter. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aranesp. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of normochromic normocytic anemia with a hemoglobin of 11.7 mg/dl.  The record does not 
indicate a diagnosis cancer or chronic renal disease.  The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85027 billed for date of service June 26, 
2020. 
 
You asked the Plan to pay for procedure code 85027. The Plan denied your request. The Plan says payment for 
code 85027 is bundled into payment for code 85025. 
 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 85027 
is a column II code to column I code 85025. 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 85027 billed for date of service June 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service May 12, 2022.