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

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service October 17, 2021. 
 You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service October 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from May 26, 
2022, to June 17, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment for home health services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required for home 
health services. Any claim with incomplete, missing, or invalid information for all of these elements may be 
returned as unprocessable. The provider should report the FIPS State and County Code of the place of 
residence where the home health service is delivered. 
 
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, we found that the FIPS code reported on the 
claim does not match the place of residence where the home health services were delivered. Therefore, we 
decided that the Plan does not have to pay for home health services billed for dates of service from May 26, 
2022, to June 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 TissueNext (81479) provided on October 5, 2021. 
 
You asked the Plan to pay for Guardant360 TissueNext. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 TissueNext 
have been met. Therefore, we decided that the Plan has to pay for Guardant360 TissueNext (81479) provided 
on October 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Liquid CDx (0239U) provided on November 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that FoundationOne Liquid CDx was ordered by 
the treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 FoundationOne Liquid CDx (0239U) provided on 
November 1, 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 parenteral nutrition services. 
 
You asked the Plan to pre-approve parenteral nutrition. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for parenteral 
nutrition have not been met. 
 
The Plan must follow Medicare rules. The rules say that parenteral nutrition is considered reasonable and 
necessary when the coverage criteria listed in the Medicare rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of parenteral nutrition have not been met. Therefore, we decided that the Plan does not have to pre-
approve parenteral nutrition services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dentures are medically 
necessary. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service September 23, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation device. You say that this item is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not have a covered 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (E0483).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 provided on October 13, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99291 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 99291 provided on October 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Multaq. 
 
You asked the Plan to pre-approve Multaq. You say that the patient has been taking this drug since 2016. The 
Plan denied your request. The Plan says this drug is not covered under the patient's medical benefits. 
 
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 Multaq.   
Benefits for Multaq 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage of pneumatic compression devices have not been met. 
 
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 
(E0652) and related supplies (E0656, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Epoetin Alfa provided to the patient from February 27, 2023, 
to March 1, 2023. 
 
You asked the Plan to pay for Epoetin Alfa. You say that you believe this drug should be paid. The Plan denied 
your request. The Plan says payment for this drug is included in the ESRD PPS payment, so no separate 
payment can be made. 
 
The Plan must follow Medicare rules. Medicare rules say that all ESRD-related injectable drugs are included in 
the ESRD PPS. If the renal dialysis facility needs to report a drug that was furnished to an ESRD beneficiary 
that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or 
service is not for the treatment of ESRD. 
 
 In this case, the drug in question was provided in a dialysis facility, which would indicate that Epoetin Alfa was 
related to ESRD. As a result, payment for this drug is bundled into the ESRD PPS payment and no separate 
payment is allowed for the drug itself. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Epoetin Alfa have not been met. Therefore, we decided that the Plan does not have to pay for 
Epoetin Alfa provided to the patient from February 27, 2023, to March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second continuous positive air pressure (CPAP) 
machine for travel. 
 
You asked the Plan to pre-approve the additional CPAP machine. You say that the CPAP machine is medically 
necessary. The Plan denied your request. The Plan says a CPAP machine has already been provided. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP machine. The requested item serves the same purpose as your current 
CPAP machine. Therefore, we decided that the Plan does not have to pre-approve a second continuous positive 
air pressure (CPAP) machine for travel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 26, 2022, to 
September 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 inpatient care. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee appeared to be stable enough for 
ongoing observation status or transfer to an in-network facility and did not require complex or intensive care 
that would suggest they were unstable for transfer. 
 
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 inpatient care have not been met.  
 
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 pay for the inpatient care. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital care provided from September 26, 2022, to September 27, 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 a genicular nerve block rendered on November 16, 2022. 
 
You asked the Plan to pay for the block. You say that this should be paid for. The Plan denied your request. 
The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee osteoarthritis 
have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that review has determined that the genicular nerve blocks are considered experimental/ investigational 
in nature. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The requested block is not reasonable or 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 the block have not been met. Therefore, we decided that the Plan does not have 
to pay for a genicular nerve block rendered on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing provided for travel purposes on 
September 3, 2022. 
 
You asked the Plan to pay for COVID-19 testing. You say that when you asked for reimbursement forms for 
this service, you were not informed that this test would not be covered for travel purposes. The Plan denied 
your request. The Plan says any services covered by the Plan must be medically necessary. This means that the 
services, supplies or drugs must be necessary for the prevention, diagnosis, or treatment of a medical condition 
and meet accepted standards of medical practice. Testing provided solely for the purpose of travel is excluded 
from coverage. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 testing have not been met. Specifically, this test was provided for travel purposes and was not reasonable and necessary for the diagnosis or treatment of an illness or injury. Therefore, we decided 
that the Plan does not have to pay for COVID-19 testing provided for travel purposes on September 3, 2022.  
 
Your complaint about the appeals process and information from the customer service representative is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and oxygen concentrator battery 
provided on November 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator and oxygen concentrator battery provided by an OON 
provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says the services received were neither emergent nor urgent and prior authorization was not 
obtained to seek out-of-network care. 
 
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 oxygen concentrator and oxygen concentrator 
battery provided on November 21, 2022, by an out-of-network (OON) provider.