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

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the associated 
administration provided on May 25, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the associated administration. You 
say that the cost share applied exceeds your maximum out-of-pocket for 2023. The Plan denied your request. 
The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $291.16 coinsurance for chemotherapy drugs and the associated administration of 
the drugs. This total is less than 20% of the allowed amount for Medicare Part B chemotherapy drugs and the 
associated administration of the drugs because your maximum out-of-pocket of $6,500 was met with the 
processing of this claim ($11,447.09 allowed x 20% = $2,289.42). These items/services fall within the 
Medicare Part B prescription drugs 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 coinsurance for 
chemotherapy drugs and the associated administration provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99203) on April 
27, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that it was your impression you would be 
covered for chiropractic services with a $20 copayment. The Plan denied your request. The Plan says this 
chiropractic service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor (99203) on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation provided by a chiropractor on June 
2, 2023. 
 
You asked the Plan to pay for the electrical stimulation. You say that you have submitted two claim forms for 
chiropractic manipulation online on August 7, 2023. You say that they were both denied because the scan was 
not clear. The Plan denied your request. The Plan says that the service is not covered when it is billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation provided by a chiropractor on June 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that a home ventilator is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 continued use of a home ventilator. Our 
reviewer says that a home ventilator is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has chronic respiratory failure from COPD. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support 
(AVAPS) capability, and failure of such a device has not been documented. 
 
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 use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says that although there are three approved power options on this wheelchair 
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the 
joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the patient is non-ambulatory and requires a power 
wheelchair for mobility and performing daily activities. They cannot perform pressure relief independently due 
to upper extremity weakness and require a power wheelchair with power tilt and recline for adequate pressure 
relief and positioning. There is a history of skin breakdown. Power elevating leg rests are required for 
positioning of the lower extremities and lower extremity spasticity. Our reviewer found that the complexity of 
the patient's seating and positioning needs necessitates a more complex group 3 power wheelchair base. The 
expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base and the three power options via a joystick. Our physician reviewer also found that these 
components are required to operate 3 or more power options on a group 3 power wheelchair. 
 
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 electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 thyroid testing provided on June 5, 2023. 
 
You asked the Plan to pay for the thyroid testing. You say that the thyroid testing was performed based on the 
ordering physician's requisition form. The Plan denied your request. The Plan says requested thyroid testing 
does not meet the Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that thyroid testing is covered when the criteria listed in 
the Medicare rules section of this decision are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the thyroid testing. Our reviewer says that 
the requested thyroid testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation in the medical records to indicate that there was a suspicion of 
thyroid disease or any other indication for the performance of thyroid function testing. 
 
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 thyroid testing have not been met. Therefore, we decided that the Plan does 
not have to pay for thyroid testing provided on June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. Code 81345 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 81345 
billed for date of service February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service May 2, 2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the testing was deemed medically necessary. 
The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 is a column II code to column I code 0089U. Code 81345 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 81345 
billed for date of service May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) months use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve 3 months use of a home ventilator. You say that you are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the request for continued 
use of a ventilator is not medically reasonable and necessary. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 3 months use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have COPD, 
severe obesity, obstructive sleep apnea, and a prior history of lung cancer. You had a sleep study with BiPAP 
titration on May 26, 2022. BiPAP at pressures of 26 inspiratory and 22 expiratory, with supplemental oxygen, 
was effective in treating the sleep disordered breathing. It appears from the records that a home ventilator was 
ordered at that time because a BiPAP device was not immediately available. The home ventilator is therefore 
being used to treat obstructive sleep apnea, which is not covered by Medicare. There is no arterial blood gas 
showing CO2 retention. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The plan 
has approved the continued use of the ventilator for 3 months, which allows time for transition to BiPAP. The 
denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 months use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve three (3) months use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service April 27, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not support at 
least 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0483 billed for date of service April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) for the upper right quadrant and 
upper left quadrant provided on March 8, 2023.  

You asked the Plan to pay for gingival irrigation (D4921) for the upper right quadrant and upper left quadrant. 
You say that you asked the provider twice if they took this insurance, and you were told yes. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) for the upper right quadrant and upper left quadrant provided on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP Interspinous Fixation device to 
L5-S1 (22840, 22612, 20930). 
 
You asked the Plan to pre-approve the Aurora Spine ZIP Interspinous Fixation device to L5-S1. You say that 
this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the Aurora Spine ZIP Interspinous Fixation device in the setting of spondylosis, spinal stenosis, and 
radiculopathy have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Aurora Spine ZIP Interspinous 
Fixation device to L5-S1. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this requested interspinous device to be an effective and/or safe 
treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial 
outcomes compared with conventional treatment. Moreover, the provided documentation does not support 
lumbar findings that would clearly require lumbar fusion. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 Aurora Spine ZIP Interspinous Fixation device to L5-S1 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Aurora Spine ZIP Interspinous Fixation 
device to L5-S1 (22840, 22612, 20930).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Abraxane. 
 
You asked the Plan to pre-approve the drug. You say that you would like to give the enrollee Abraxane over 
docetaxel due to their inability to tolerate docetaxel. The Plan denied your request. The Plan says that Abraxane 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Abraxane is medically necessary. Our physician reviewer found that the requested used of Abraxane is 
supported by one of the major drug compendia and by clinical research. Abraxane is also safe and effective and 
otherwise reasonable and necessary for the enrollee. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Abraxane.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on October 15, 2022, 
to October 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the diagnosis is not clinically validated.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with primary diagnosis code A41.51, defined as sepsis due to 
Escherichia coli [E. coli]. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our physician reviewer found that the enrollee presented with 
shortness of breath, in the setting of a known urinary tract infection (UTI). Imaging showed pleural effusions 
and mediastinal lymphadenopathy. The enrollees respiratory symptoms improved with diuresis. The enrollee 
completed therapy for her UTI. There is no evidence of sepsis (i.e., hypotension, hypoperfusion, organ failure).  
As such, the billing of A41.51 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on October 15, 2022, to October 19, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade 
to expandable controller (E2313), and electronic connection between wheelchair controller and two or more 
power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has sufficient strength and 
function in upper extremities to manage standard power drives. 
 
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 expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for 
upgrade to expandable controller (E2313), and electronic connection between wheelchair controller and two or 
more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9276 and A9278 provided on June 13, 
2023, and June 26, 2023. 
 
You asked the Plan to pay for procedure codes A9276 and A9278. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the items are not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that codes A9276, A9277, A9278, and A9279 will be 
denied as non-covered as they do not meet the DME benefit category requirements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sensor (A9276) and receiver (A9278) for use with a non-durable medical equipment interstitial 
continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes A9276 and A9278 provided on June 13, 2023, and June 26, 2023.