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

 
We decided that the Plan does not have to pay for lab services (81194, 81206, 81292, 81295, 81298, 81301, 
81317, 81321, 81401) provided August 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81194, 81206, 81292, 81295, 81298, 81301, 81317, 81321, 
81401) provided August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contract language indicating that these services are included in the dialysis rate. The Plan denied 
your request. The Plan says payment for these services is the responsibility of the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of venous blood by venipuncture and an office 
visit provided on December 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of venous blood by venipuncture and an office visit. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says This provider is not a 
network provider with the Plan, and they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
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 collection of venous blood by venipuncture and an 
office visit provided on December 29, 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 portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you appear to only require BiPAP 
with AVAPS based on recent documentation. There was no report of failure of this device to justify a home 
ventilator 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71046) provided on September 
8, 2021. 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has denied correctly as a 
duplicate. 
 
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 71046 is radiologic examination, chest; 2 views. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, this documentation 
presented does not support additional payment for the X-ray services beyond what has been paid. Based on this 
information, we decided that Medicare rules for coverage of the X-ray exam of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the chest (71046) provided on 
September 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the debridement of nails (11721) provided on July 20, 2021. 
 
You asked the Plan to pay for the debridement of nails. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this claim was billed with an 
inappropriate place of service code. 
 
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. Specifically, the Plan has not forwarded any evidence as to why the place of 
service billed on the claim is inappropriate. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Health Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the debridement of nails (11721) provided on July 20, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transport services received on October 6, 
2021. 
 
You asked the Plan to pay for the services. You say that this should have been covered. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transport services received on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extremity study to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve an extremity study. You say that you had a stroke 4 years ago that resulted 
in blood clots and you want to check to see if you have any blood clots as well as to prevent more from 
forming. The Plan denied your request. The Plan says this provider's office is not contracted with your 
insurance to provide ultrasound services in their office. 
 
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 providers office in this case is not a network provider with the Plan. The Plan has network 
providers available who can provide the services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve an extremity study to be provided by the requested provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from December 19, 2021, to December 20, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that having Medicare Part D coverage, you 
would hope that the charges will be reimbursed to you.  The Plan denied your request. The Plan says the self-administered drugs received under observation care do not 
qualify for reimbursement under Medicare Part A and B 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 pay for the self-administered drugs 
provided in an outpatient setting from December 19, 2021, to December 20, 2021.  
 
Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) and surgical 
preparation of recipient site (15004) provided on June 8, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer (14301 and 14302) and surgical preparation of 
recipient site (15004). You say that the size is documented by measurements as well as location which meets 
the coding. You say that the denial is inaccurate, and the claim should be paid. The Plan denied your request. 
The Plan says procedure codes 14301, 14302 and 15004 are not supported by the medical records submitted. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 14302 is adjacent tissue 
transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to 
code for primary procedure). The CPT Code Manual definition of code 15004 is surgical preparation or 
creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or 
incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or 
multiple digits; first 100 sq cm or 1% of body area of infants and children 
 
We asked our coder 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 adjacent tissue transfer (14301 and 14302) and surgical 
preparation of recipient site (15004). Our reviewer says that the documentation submitted was reviewed and 
does not meet the criteria for coverage. Our reviewer found that the operative report describes an advancement 
flap and there is a more appropriate code to report for these procedures. Therefore, CPT codes 14301 and 
14302 cannot be verified. In addition, the operative report does not include documentation of a surgical 
preparation or creation. Per the NCCI Policy Manual, the documentation does not support tissue prepared to 
receive a free skin graft needed to close or repair a defect. Therefore, procedure code 15004 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the adjacent tissue transfer (14301 and 14302) and surgical preparation of 
recipient site (15004) have not been met. Therefore, we decided that the Plan does not have to pay for the 
adjacent tissue transfer (14301 and 14302) and surgical preparation of recipient site (15004) provided on June 
8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Intraosseous Nerve Ablation System 
procedure (64628, 64629). 
 
You asked the Plan to pre-approve a back procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet 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 a back procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. It has not been shown to be safe 
and effective in long term studies. 
 
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 back procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept Intraosseous Nerve Ablation System procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331) and a power elevating seat 
(E2300). 
 
You asked the Plan to pre-approve an attendant control and power elevating seat. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the attendant control is not medically 
necessary, and the power elevating seat is not a covered item. 
 
The Plan follows Medicare rules. Medicare rules say that only medically necessary items are 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 attendant control and power 
elevating seat. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation submitted does not support that the requested item is 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 an attendant control and power elevating seat have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an attendant control (E2331) and a power elevating seat 
(E2300).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from January 13, 2022, to January 14, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not have to pay for 
anything, and the Plan should pay for the medical services. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for an in-network emergency room visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$90 copayment for an ER visit. An ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an emergency room (ER) visit provided from January 13, 2022, to 
January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require 
transportation to your dialysis treatment. The Plan denied your request. The Plan says that you have exhausted 
this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) 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 additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips for the enrollee. You say that the 
enrollee requires transportation. The Plan denied your request. The Plan says that the enrollee has exhausted 
this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of thirty-six (36) 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 additional routine transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for the Freestyle Libre continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM sensors. You say that you feel that this should be 
covered because it is helpful for your blood sugar control. The Plan denied your request. The Plan says you do 
not meet the Medicare criteria for coverage of the CGM. 
 
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 the enrollee does not use insulin 
with at least three daily administrations. It is noted you use one dose of insulin per day before bed. Based on 
this information, we decided that Medicare rules for coverage of the requested CGM sensors have not been 
met. Therefore, we decided that the Plan does not have to pre-approve sensors for the Freestyle Libre 
continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left side Percutaneous implantation of Neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555) and Lead, neurostimulator (implantable) 
(C1778). 
 
You asked the Plan to pre-approve Left side Sprint PNS placement. You say that since he was previously 
approved and benefited from this treatment, he should be approved for it again to resolve his left low back pain. 
The Plan denied your request. The Plan says the Sprint PNS device does not meet the Medicare or health Plan 
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 Left side Sprint PNS placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental/ investigational. The request is therefore, 
deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Left side Sprint PNS placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve left side Percutaneous implantation of Neurostimulator electrode array; 
peripheral nerve (excludes sacral nerve) (64555) and Lead, neurostimulator (implantable) (C1778).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
neutropenia associated with myelodysplastic syndrome. The Food and Drug Administration (FDA) 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. The 
services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Udenyca.