Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on August 29, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0480 and 80307 is drug test(s), definitive, utilizing (1) drug identification methods able to identify 
individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but 
not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding 
immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable 
isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, 
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched 
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) 
if performed. 
  
We find that CPT code G0480 is supported in the medical record. Specifically, the lab report clearly shows that 
1-7 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on August 29, 2017.  
 
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 localized delivery of antimicrobial agents (D4381) 
provided on April 1, 2022. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that you feel this 
treatment is recommended to prevent tooth extraction. The Plan denied your request. The Plan says your plan 
does not cover this procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents (D4381) provided on April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty. 
 
You asked the Plan to pre-approve knee arthroplasty. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that knee arthroplasty is only covered for certain 
indications. 
 
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 knee arthroplasty. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have been treated for unilateral primary osteoarthritis of the left knee. You 
presented with bilateral knee pain that has been present for two years. The pain is located in the anterior, 
lateral, and medial region of the knee. The pain is sharp and moderate and worse with activities. The symptoms 
are worse when standing, squatting, kneeling, climbing stairs, and walking. The exam reveals an antalgic gait. 
There is moderate effusion. There is severe medial joint line and moderate peripatellar tenderness. Crepitus is 
noted with range of motion. Patellofemoral crepitus and patella grind are both positive. X-rays are noted to 
show moderate arthritis in the patellofemoral compartment; severe arthritic changes are noted in the medial 
compartment; severe joint space narrowing, marginal bone spur, subchondral cyst formation, and osteophyte 
formation. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are not distinct structural abnormalities, such 
as: distal femur fracture; proximal tibia fracture; malignancy of the distal femur, proximal tibia, knee joint or 
adjacent soft tissues; avascular or other form of osteonecrosis of the knee; rheumatologic changes precluding or 
inconsistent with rehabilitation demonstrated. The documentation does not support a previous failed joint 
replacement/arthroplasty necessitating revision. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
you do not have a diagnostic/condition that meet criteria for the requested services and requested knee 
arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home COVID-19 test purchased on January 23, 2022. 
 
You asked the Plan to pay for the home COVID-19 test. You say that you were eligible to be reimbursed for up 
to 8 tests per month, despite the set date being February 1, 2022. The Plan denied your request. The Plan says 
this was not a covered benefit at the time you purchased this test. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the home 
COVID-19 test is an OTC item. However, the Plan offers a supplemental benefit for over-the-counter home 
COVID-19 tests purchased after February 1, 2022. These tests were purchased on January 23, 2022, which is 
before this benefit went into effect. Therefore, we decided that the Plan does not have to pay for the home 
COVID-19 test purchased on January 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on September 19, 2017. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is supported in the medical record. Specifically, we find that CPT code G0480 is 
supported in the medical record. Specifically, the lab report clearly shows that 15-21 drug classes were tested in 
this case. Please note, we counted the classes based on the separately billable tests from the CPT Handbook. 
Also, the record indicates that this provider was directed by the Plan to not obtain records. With this direction, 
it is inappropriate for the Plan to deny these services based on the physician signature. Based on this 
information, we decided that Medicare rules for coverage of the drug testing services have been met. Therefore, 
we decided that the Plan has to pay for the drug testing services provided on September 19, 2017.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim to be reconsidered 
for payment. The Plan denied your request. The Plan says the services were rendered by a non-participating 
provider. The Plan also says that there is no referring provider, and prior authorization was not 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 
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 the medical services provided on July 7, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
9, 2022. 
 
You asked the Plan to pay for procedure code 70450-26. You say that you billed this claim with the correct 
Place of Service (POS) code. The Plan denied your request. The Plan says this claim was billed with an 
incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that if you furnish services to a hospital inpatient, you 
must bill POS 21 (inpatient hospital). Records show that the enrollee was inpatient status at the time of service. 
However, this claim was billed with POS 22, which is for outpatient hospital. Because the enrollee was an 
inpatient, reporting of POS 22 is not appropriate in this case. Based on this information, we decided that 
Medicare rules for coverage of procedure code 70450-26 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 70450-26 billed for date of service February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam with photos (92250) provided on February 3, 
2022. 
 
You asked the Plan to pay for the eye exam with photos. You say that you believe this service was denied due 
to a coding error. The Plan denied your request. The Plan says this service is not covered by the Plan. 
 
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 the services listed in the 2022 Evidence of Coverage. 
 
We looked at the file and the Plan's rules. Specifically, eye exam with photos (92250) is not listed as a covered 
benefit. Based on this information, we decided that the Plan's rules for coverage of the eye exam with photos 
have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the eye exam with photos (92250) provided on 
February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve Farxiga. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered 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 Farxiga.  
 
Benefits for Farxiga 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased on November 29, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that these eyeglasses should be covered because your 
eyes got weaker as a result of having Shingles.  You said that because this was a medical issue, it should be 
covered under your medical benefits. The Plan denied your request. The Plan says eyeglasses are only covered 
following cataract surgery. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear except following cataract surgery. This rule applies even if the reason why you needed glasses is 
because of another medical issue. 
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for eyeglasses you purchased on November 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with biopsy (45380), colonoscopy with 
directed submucosal injection(s) (45381), and colonoscopy with lesion removal (45385) provided on March 24, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the colonoscopy services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says these services were rendered by a non-
participating provider, and the enrollee was referred by another non-participating provider. The Plan also says 
that these services were not authorized by the Plan. 
 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 
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 the colonoscopy with biopsy (45380), 
colonoscopy with directed submucosal injection(s) (45381), and colonoscopy with lesion removal (45385) 
provided on March 24, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CMG). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for your 
diabetes management. 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CMG).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the drug is not being 
prescribed for a medically accepted indication. 
 
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 physician reviewer found 
that you have chronic kidney disease and anemia. Your iron stores remain low. It is noted that intravenous iron 
has been administered on at least two occasions. There is no documentation that the iron deficiency has been 
successfully treated. With low iron, Aranesp is not indicated. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional one-way trips. 
 
You asked the Plan to pre-approve additional trips. You say that you do not have any other means of 
transportation. You also say that you are to have hip and knee surgeries and need additional rides. The Plan 
denied your request. The Plan says you have exhausted the number of allowable trips, and additional trips are 
not covered. 
 
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 up to 30 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional one-way trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan with the chest 
without and with contrast (71270). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer 
says that the criteria for a CT scan of the chest were not met. Our physician reviewer found a low-dose CT 
(LDCT) scan would be appropriate in this case. 
 
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 chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan with the chest without and with contrast 
(71270).