Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided November 15, 2021. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, records show that the 
enrollee was not a new patient to this provider. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
office visit (99204) provided November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, 88360, and 
88381 provided on September 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
the documentation shows that these codes have a physician fee schedule professional component/technical 
component of 1. The claim was billed with place of service 22 (outpatient). The professional interpretation of a 
diagnostic test must be separately billed with modifier  26 by the interpreting physician. This means the claim 
was billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 88341, 88342, 88360, and 88381 provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 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 services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your 
request. The Plan says a trial of at least 2 plan preferred drugs is required before alternatives can be considered. 
Plan preferred drugs include Humira, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, or Xeljanz XR, 
Orencia or Enbrel. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the record does not show a trial of 2 of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are 
requesting an appeal to review the coverage denial for a Flexitouch PCD for the treatment of the enrollee's 
lymphedema. The Plan denied your request. The Plan says the enrollee's lymphedema does not extend to the 
chest trunk and/or abdomen and therefore the enrollee does not meet the Medicare criteria. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. A PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the enrollee only has lymphedema to both lower 
extremities. The enrollee does not have lymphedema extending to the chest trunk and/or abdomen. Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283) provided January 28, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim did not include a required modifier. 
 
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 99283 is not supported in the medical record. Specifically, the record shows the 
enrollee was incarcerated at the time service were rendered. The required QJ modifier was not submitted on the 
claim. Based on this information, we decided that Medicare rules for coverage of the emergency room services 
have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services 
(99283) provided January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81406, 81404, 81405, 81403, 81402, 81401, 
81400, 81275) provided March 5, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Plasma-Based Genomic Profiling in 
Solid Tumors service, providers must bill 1 unit of service for the appropriate CPT code (81479 or 81445). 
 
We looked at the file and Medicare rules. In this case, multiple unbundled codes were submitted for a single 
genetic testing panel. 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 genetic testing (81406, 
81404, 81405, 81403, 81402, 81401, 81400, 81275) provided March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on April 15, 2022. 
 
You asked the Plan to pay for chiropractic care. The Plan denied your request. The Plan says as a managed care 
Plan Medicare rules allow us to restrict members to our network and deny out of network care except in rare 
circumstances. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic care provided on April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage chair purchased on November 15, 2021. 
 
You asked the Plan to pay for these services. You say that you confirmed you would be reimbursed prior to 
purchasing. The Plan denied your request. The Plan says the services are not covered. 
 
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. The Plan 
reviewed your call history and confirmed that you were informed that the massage chair is not normally 
covered under Medicare. Therefore, we decided that the Plan does not have to pay for the massage chair 
purchased on November 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says your needs can be safely met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that SNF 
care is not medically necessary. Our physician reviewer found that you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection, aflibercept, 1 mg  
(code J0178) provided on February 24, 2022. 
 
You asked the Plan to waive the coinsurance for an injection, aflibercept, 1 mg. You say that there should be a 
zero copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee has been asked to pay 20% coinsurance for an injection, aflibercept, 1 mg. The injection, 
aflibercept, 1 mg falls within the Medicare Part B prescription drugs benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an injection, aflibercept, 1 mg (code J0178) provided on  
February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guaiac-based fecal occult blood tests (gFOBT) rendered 
on July 1, 2021 to September 7, 2021. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services exceed the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers a gFOBT screening once every 12 
months 
 
We looked at the file and Medicare rules. The file shows that you previously had a gFOBT screening on 
January 6, 2021 that the Plan covered. The tests on July 1, 2017 and September 7, 2021 were performed less 
than 12 months from your previously covered test. Therefore, we decided that the Plan does not have to pay for 
the guaiac-based fecal occult blood tests (gFOBT) rendered on July 1, 2021 to September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool and transfer bench. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the items for several 
diagnoses. The Plan denied your request. The Plan says the services are not covered. 
 
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 tub stool and transfer bench.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81276, 81272, 81210, 81275) provided 
November 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single geniting testing 
panel. 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 genetic testing (81276, 81272, 81210, 
81275) provided November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza. 
 
You asked the Plan to pre-approve Tepezza. You say that Tepezza is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Tepezza. Our reviewer says that 
Tepezza is not medically necessary. Our physician reviewer found the records do not document that the 
patient's diabetes is under adequate control for use of the Tepezza. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tepezza.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographing recording (CPT code(s): 93228 and 93229) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the services may be obtained 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
external mobile cardiovascular telemetry with electrocardiographing recording (CPT code(s): 93228 and 
93229) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flip forward back cane (K0108) 
 
You asked the Plan to pre-approve a flip forward back cane. You say that the requested item is needed for 
transporting your wheelchair into your van. The Plan denied your request. The Plan says the requested item is 
solely for use outside the home and is not a covered benefit of Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a flip forward back cane (K0108)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81201, 81209, 81162, 
81242, 81295, 81298, 81401, 81404, 81405, 81408, 81307, 81435, 81403, 81406, 81407 and 81479 provided 
May 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached medical records that 
includes the services performed. The Plan denied your request. The Plan says there is evidence of 
misrepresented services.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There is no evidence of an established relationship between the 
enrollee and the ordering physician as required per CMS guidelines. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 81201, 81209, 81162, 81242, 81295, 81298, 81401, 
81404, 81405, 81408, 81307, 81435, 81403, 81406, 81407 and 81479 provided May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0651). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the pneumatic compression 
device is medically necessary. The Plan denied your request. The Plan says the records do not show objective 
measurements to support that a 4 week trial of conservative treatment was performed. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0667, E0651).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2021 by an 
out-of-network (OON) provider. 
 
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 services were rendered by an out-of-network provider without prior authorization. 
 
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 the laboratory services provided on December 1, 
2021 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 power wheelchair cupholder, bag holder, and 
expandable controller. (K0108, K0108, E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that items that are not primarily medical in nature are non-
covered. Expandable controllers are covered only when 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 the power wheelchair accessories. Our reviewer says that he requested items are not medically necessary. Our physician reviewer found the cup holder 
and bag holder are not primarily medical in nature and are therefore non-covered. The records show that the 
enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with 
their own switches. 
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair cupholder, bag holder, and expandable controller. 
(K0108, K0108, E2311, E2377, E2313).