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

 
We decided that the Plan does not have to pay for the genetic testing provided on July 2, 2021, billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and were billed appropriately. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 2, 2021, billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service February 18, 
2022. 
 
You asked the Plan to pay for procedure code 72170. You say that this service is not a duplicate claim and was 
billed correctly. The Plan denied your request. The Plan says payment for code 72170 is bundled into payment 
for code 73501. 
 
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 72170 
is a column II code to column I code 73501. 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 72170 billed for date of service February 18, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services 
 
You asked the Plan to pre-approve SNF. You say that you need SNF care. The Plan denied your request. The 
Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF services
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home-health services (G0151, 1EB21, Q5001) provided on 
February 1, 2022 to February 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home-health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 home-health services (G0151, 1EB21, Q5001) 
provided on February 1, 2022 to February 15, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital procedure provided 
on March 24, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital procedure. You say that you should not 
have this copayment. The Plan denied your request. The Plan says the copayment applied was 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 a $375 
copayment for in-network outpatient surgery services.  
 
You have been asked to pay a $375 copayment for an outpatient hospital procedure. An outpatient hospital 
procedure falls within the In-Network Outpatient Surgery 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 an outpatient hospital procedure provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair you purchased on March 22, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that the Plan approved you to get a rental chair, but you 
thought it would be better to buy it instead.  You said that you were told this would be okay. The Plan denied 
your request. The Plan says you purchased this wheelchair from a supplier that does not participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair you purchased on March 
22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 28, 2021. 
 
You asked the Plan to pay for psychotherapy. 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 the provider must attempt to consult the 
attending or primary care physician about the services furnished. 
 
  The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer smart implantable pulse generator system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the efficacy is still uncertain at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that the implantation of a cardiac contractility modulation system in the form of the Optimizer 
Smart device (CCM) was requested. 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 
requested services. Our physician reviewer found that the enrollee has left ventricular dysfunction with 
continued symptoms, despite medical treatment, thought to reflect congestive heart failure. An exhaustive 
review of the current medical literature pertaining to the CCM system confirms multiple observational studies 
suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been 
reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful 
improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA 
approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, I would 
not consider the CCM system to be medically necessary in this patient. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Optimizer smart implantable pulse generator system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog mix flexpen (J1815). 
 
You asked the Plan to pre-approve Novolog. You say that the requested drug is medically necessary for the 
enrollee. 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 Novolog mix flexpen 
(J1815).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the 
information provided the requested MRI should be denied as medically unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lenvima (C9399). 
 
You asked the Plan to pre-approve Lenvima. You say that the requested drug is medically necessary for the 
enrollee. 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 Lenvima (C9399).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 96976. 
 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 76700 
is a column II code to column I code 96976. 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 76700 billed for date of service March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig you purchased on April 9, 2022. 
 
You asked the Plan to pay for the wig. You say that you believe this item should be covered. The Plan denied 
your request. The Plan says wigs are not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig you purchased 
on April 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of chest without contrast 
(71250). 
 
You asked the Plan to pre-approve CT scan. You say that the medical records submitted were prior x-ray 
results for the enrollee. The Plan denied your request. The Plan says the requested CT scan is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has no pulmonary symptoms and has not had a chest x-ray. Therefore, the reviewer 
found that the provided documentation does not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) of chest without contrast (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible and copayment for destruction of skin lesions 
and a specialist office visit provided on May 11, 2022. 
 
You asked the Plan to reduce the deductible and copayment for the destruction of skin lesions and specialist 
visit. You say that you feel the charges for the services are unreasonable. The Plan denied your request. The 
Plan says the correct deductible and copayment were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each in-person specialist 
visit. 
 The destruction of skin lesions fall within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $750 deductible which applies to certain items and services. 
This cost sharing is a contractual obligation that had not been met at the time the destruction of skin lesions 
were performed on May 11, 2022. You have also been asked to pay a $35 copayment for the specialist visit. 
The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. The total for the visit is $153.47. Therefore, we decided that the Plan does not have to reduce the 
deductible and copayment for destruction of skin lesions and a specialist office visit provided on May 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 27, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice at 
the time of service. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 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 ambulance services provided on February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on January 10, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 seat lift mechanism (E0627) provided on 
January 10, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for X-rays of the chest and a computed 
tomography (CT) scan of the thorax provided on April 4, 2022. 
 
You asked the Plan to waive the copayments for the X-rays and CT scan. You say that the X-rays and CT scan 
should be fully covered per your authorization on file. 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 $40 
copayment for X-rays and ultrasounds and a $150 copayment for each MRI, CT, or PET scan.  
 
You have been asked to pay a $40 copayment for the X-rays. You have also been asked to pay $103.58 for the 
CT scan, which is less than the $150 copayment. The X-rays and CT scan fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The total for both services is $143.58. 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 copayments for X-rays of the chest and a computed tomography (CT) scan 
of the thorax provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on January 10, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $10 
copayment for individual therapy visits. Covered services include mental health services provided by a state-
licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse 
practitioner, physician assistant or other Medicare-qualified mental health care professional as allowed under 
applicable state laws. 
 
You have been asked to pay a $10 copayment for office visit. Office visit falls within the Outpatient mental 
health 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 office visit on January 10, 
2022.