Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the bilateral lumbo-sacral, hip, femur orthosis provided on March 29, 
2022. 
 
You asked the Plan to pay for the back/hip/femur brace. You say that the enrollee was seen face-to-face in 
December when they received a steroid injection for hip/leg pain. The pain subsequently returned and the 
treating provider ordered the braces at issue, for which proof of delivery was submitted. The Plan denied your 
request. The Plan says that there is no mention of the ankle orthosis billed in the referring physician records 
submitted 
with the appeal. In addition, there is no delivery confirmation for the ankle orthosis. 
 
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. The Plan has not provided a valid denial rationale in this case. The rationale cites 
that the delivery confirmation did not confirm delivery of an ankle-foot orthosis; however, no ankle-foot 
orthosis is being billed. The delivery ticket shows that a hip brace was sent for delivery on March 29, 2022. 
Without a valid rationale, we find that the denial of payment is not supported. Therefore, we decided that the 
Plan has to pay for the bilateral lumbo-sacral, hip, femur orthosis provided on March 29, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam of the hip provided on August 18, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray exam of the hip. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there was no prior authorization was obtained for this 
service. The Plan also says that an out-of-network provider with the Plan, and authorization is required for out-
of-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an x-ray exam of the hip provided on August 18, 
2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
February 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. 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 $35 
copayment for each physical therapy visit.  
 You have been asked to pay a $35 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services 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 physical 
therapy (PT) services provided on December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix for wound treatment for the enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is being done for a wound of less than one square centimeter. 
 
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 the treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a diabetic ulcer in the left foot measuring 0.8 cm x 0.7 cm x 0.3 cm 
improving with basic wound care. Epifix skin graft was requested for wound treatment. However, based on the 
provided documentation, the wound intended to be treated with Epifix is less than 1 cm square. MNG #44 
guidelines require at least 1 square cm in size to treat with grafting. Therefore, this request for such will be 
considered not 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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epifix for wound treatment for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 3, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you only went to the ER to get sutures 
removed you shouldn't be charged for that. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $90 
copayment for each Medicare-covered visit.  
 
You have been asked to pay $66.06 which is less than the standard $90 copayment for ER visit. ER visits fall 
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 ER visit 
provided on March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of osteoporotic fracture or a trial of drug zoledronic acid before they will approve the 
requested drug. The enrollee does not have a history of osteoporotic fracture nor has tried and failed the 
required drug. The documentation does not support that zoledronic acid would likely be less effective and/or 
would likely have adverse effects for the enrollee 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82310 and 84100 billed for date of service 
January 12, 2022. 
 You asked the Plan to pay for procedure codes 82310 and 84100. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 82310 and 84100 is bundled into 
payment for code 80069. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
82310 and 84100 are column II codes to column I code 80069. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 82310 and 84100 billed for 
date of service January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination of Ipratropium and Albuterol 0.5-3 (2.5) 
mg/3ml to be inhaled one vial by a handheld nebulizer. 
 
You asked the Plan to pre-approve the combination of Ipratropium and Albuterol to be used in a nebulizer. You 
say that this medication is administered via a handheld nebulizer, and is not administered at home. You also 
say that this medication is not a compounded nebulizer solution. The Plan denied your request. The Plan says 
this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for administering 
additional Albuterol sulfate (J7611, J7613), Levalbuterol (J7612, J7614) and/or Ipratropium bromide (J7644) 
has not been established. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the combination of Ipratropium and Albuterol to be used in a nebulizer have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a combination of Ipratropium and Albuterol 
0.5-3 (2.5) mg/3ml to be inhaled one vial by a handheld nebulizer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you moved and needed to find a new dentist 
office. You say that you were not satisfied with the first one you saw. You say that this dentist required x-rays 
as you had not been seen there before. You also say that you would like to see if something can be done about 
this. The Plan denied your request. The Plan says your benefit for the panoramic x-ray 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 panoramic x-ray was exhausted on date of service November 12, 2021. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service January 19, 
2022. 
  You asked the Plan to pay for procedure code 11721. You say that the physician provided medically necessary 
services and the services meet professionally recognized standards of healthcare. You say that the claim should 
be processed for payment. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11721 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 11721 billed for date of service January 19, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for rehabilitation services provided on December 
16, 2021. 
 
You asked the Plan waive the copayment for rehabilitation services. You say that you have a limited income 
and cannot afford the copayment. The Plan denied your request. The Plan says the cost share was applied 
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). Your contract with the Plan clearly says that you must pay a $35 
copayment for rehabilitation services.  
 
 You have been asked to pay a $35 copayment for rehabilitation services. Rehabilitation services falls within the 
Outpatient Rehabilitation Services 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 waive the copayment for 
rehabilitation services provided on December 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 3, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the member's specimens were sent to your 
laboratory as per the order from an in-network referring provider. The Plan denied your request. The Plan says 
the rendering provider is a non-participating provider. The Plan also says that the referring provider involved in 
these services is a non-participating provider with the Plan. The Plan also says that they did not authorize any 
services for the rendering or referring provider. 
 
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 laboratory services provided on April 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Next Generation Sequencing (NGS) testing provided on June 4, 
2021. 
 
You asked the Plan to pay for the NGS testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that that there is a Local Coverage Determination 
(LCD) that indicates that any panel that tests for the FANCC and BLM genes are noncovered. Since this panel 
includes that, the denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to an enrollee with a solid tumor. 
The FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale 
was presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the NGS 
testing have been met. Therefore, we decided that the Plan has to pay for the Next Generation Sequencing 
(NGS) testing provided on June 4, 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 the laboratory services coded 87798, 87653, 87640, and 
87624 provided on October 5, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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. 
 
Review of the file shows that there was no clinical documentation provided to support the necessity of the 
testing provided. Without this required documentation, the documentation does not support that the test at issue 
in this appeal was not requested solely for non-screening purposes. Medicare does not cover this testing solely 
for screening purposes. In addition, the standard of care for the evaluation of urinary tract infection is urinalysis 
with urine culture and sensitivity. The urine polymerase chain reaction (PCR) testing is considered unproven 
and not medically necessary. Therefore, we decided that the Plan does not have to pay for the laboratory 
services coded 87798, 87653, 87640, and 87624 provided on October 5, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 10, 2022. 
 
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 that the services were not billed correctly. 
 
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. The Plan states that the claim was not billed with the required DEX-Z code, per 
Local Coverage Determination (LCD) L35025; however, this LCD is not valid for the state of Massachusetts 
where the testing is performed. The Plan has not provided any documentation or Medicare rules to support that 
the testing is not covered. Therefore, we decided that the Plan has to pay for the FANCC genetic testing 
rendered on February 10, 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.