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

 
We decided that the Plan does not have to pre-approve Xiidra drops. 
 
You asked the Plan to pre-approve Xiidra drops. You say that the drug is necessary. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Xiidra drops.  
 Benefits for Xiidra drops 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 knee arthroscopy (29876) provided on October 21, 2021. 
 
You asked the Plan to pay for the knee arthroscopy (29876). The Plan denied your request. The Plan says CPT 
code 29876-59-LT is not supported in the documentation and is not payable. 
 
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 29876 is arthroscopy, knee, surgical; synovectomy, 
major, 2 or more compartments (eg, medial or lateral). 
 
 
  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 knee arthroscopy (29876). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include enough documentation to support a synovectomy procedure was 
medically necessary and not a "clean up". Therefore, CPT code 29876 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 knee arthroscopy (29876) have not been met. Therefore, we decided that the 
Plan does not have to pay for the knee arthroscopy (29876) provided on October 21, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the placement of soft tissue localization device (10035) provided on 
May 13, 2020. 
 
You asked the Plan to pay for the placement of soft tissue localization device (10035). You say that the patient 
had multiple exams on this date of service. You say that the attached reports support the level of service, and 
the claim should be reconsidered for processing. The Plan denied your request. The Plan says that CPT code 
10035 is included in CPT code 19083 and not separately reimbursed. 
 
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 did not submit a claim showing that CPT code 19083 was billed on the 
same date for CPT code 10035 to be included. Therefore, we decided that the Plan has to pay for the placement 
of soft tissue localization device (10035) provided on May 13, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power lift recliner chair and sales tax provided on October 
26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a power lift recliner chair and sales tax. You say that the items were medically 
necessary. The Plan denied your request. The Plan says prior authorization is required for items purchased out-
of-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 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 a power lift recliner chair and sales tax provided 
on October 26, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided in the emergency 
room on September 20, 2021 to September 21, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that this service should be covered. The 
Plan denied your request. The Plan says the types of drugs provided are not eligible for coverage under the Part 
B medical benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) 
provided in the emergency room on September 20, 2021 to September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
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 perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
after March 21, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that you continue to require SNF care. The 
Plan denied your request. The Plan says SNF care is no longer medically reasonable and necessary. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that you are a 69-year-old male with 
a past medical history of colon cancer, colostomy status, hypertension, hyperlipidemia and sleep apnea who 
was admitted to a skilled nursing facility for skilled nursing and therapy services on February 3, 2022, for 
treatment of multiple abdominal wounds. You required daily skilled nursing wound care and services with 
physical and occupational therapy. As of March 17, 2022, you were walking 500 feet with a wheeled walker 
with modified independence and was modified independent for transfers and activities of daily living. In this 
case, there continue to be skilled nursing and skilled therapy needs. However, based on the medical records 
provided there is no documentation that daily skilled services are required. You are walking household 
distances with a wheeled walker with modified independence and are modified independent for transfers. In 
this case, there is no documentation that you require the services on an inpatient basis, only in a skilled nursing 
facility setting. Services in the home with home health care or in a long-term care facility on a part time basis 
appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care after March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81210, 81235, 81275, 81276, 81295, 
81298, 81301, 81317, 81401, 81194, 81309, 81206, and 81292) provided on May 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 laboratory services (81210, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194, 
and 81309) 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. 
 
The rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. We find that codes 81206 and 81292 are not supported in the medical record. 
Specifically, the testing at issue in this case should be reported with CPT code 81479.  
 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81210, 81235, 81275, 
81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309, 81206, and 81292) provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
(83789) provided on October 5, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry (83789). The Plan denied 
your request. The Plan says CPT code 83789 remains not supported. 
 
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 83789 is a column II code to column I codes 80307 and G0480; 
however, 83789 was billed with a modifier.  
 
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 mass spectrometry and tandem mass spectrometry 
(83789). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that the documentation describes an office visit, with no laboratory testing 
results documented. Therefore, CPT code 83789 cannot be verified as performed. 
 
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 mass spectrometry and tandem mass spectrometry (83789) have not been 
met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry (83789) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152 and 99153) provided 
on August 17, 2021. 
 
You asked the Plan to pay for codes 99152 and 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 99152 is  Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
We have confirmed that code 99153 is an add-on code to code 99152. As the primary procedure code cannot be 
paid, code 99153 is also not payable. Based on this information, we decided that Medicare rules for coverage of 
codes 99152 and 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the 
moderate sedation services (99152 and 99153) provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PUREWICK TM external female catheter. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is a disposable, non-reusable hygiene items that falls outside the 
scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve PUREWICK TM external female 
catheter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (88305) services provided on April 8, 
2021. 
 
You asked the Plan to pay for code 88305. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Based on this information, we 
decided that Medicare rules for coverage of code 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical pathology (88305) services provided on April 8, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee's labs are concerning for an 
evolving myeloproliferative neoplasm. The Plan denied your request. The Plan says that an appropriate 
diagnosis has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for myeloproliferative disease is 
only covered under certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genetic testing. Our physician reviewer 
found that the enrollee has thrombocytosis. Her platelet count was 678, and her white blood cell count was 9.3. 
BCR-Abl is used to diagnosed CML. In those with platelet counts greater than 600, CML is in the differential 
diagnosis. Given elevated platelets count the use of BCR-Abl is reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing.  
 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 provided on June 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 laboratory 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 the laboratory services provided on June 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 27, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel the previously benefited exam should 
not have been billed to your insurance. You say that you had to switch dentists. You say that the new dentist 
would not see them until they could complete an exam. You also say that you would like the exam on the date 
of service in this case to be covered. The Plan denied your request. The Plan says the frequency limit has been 
exceeded. 
 
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 and 2 oral exams are covered per 
calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams that 
you received on February 22, 2021, and March 31, 2021. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on October 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that you thought your premiums would cover 
pain management. The Plan denied your request. The Plan says the amount reimbursed was correct. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that you were reimbursed for the acupuncture services 
based on the Medicare allowed amount. Therefore, we decided that the Plan does not have to further pay for the 
acupuncture services provided on October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation and services provided on October 
5, 2021. 
 
You asked the Plan to pay for the psychiatric evaluation and services. You say that you would like to be 
reimbursed for these services. The Plan denied your request. The Plan says these services were rendered by a 
provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
psychiatric evaluation and services provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reading device (E1399). 
 
You asked the Plan to pre-approve a reading device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this device can be used be used by those without illness as a reading device. 
 
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 reading device (E1399).