Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional fractions of image-guided, intensity-
modulated radiation therapy (IG-IMRT) (G6002, G6015, 770014). 
 
You asked the Plan to pre-approve additional fractions of IG-IMRT. You say that the additional fractions are 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare guidelines say 
more than 35 radiation treatments would not be generally accepted or standard. 
 
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 additional fractions of IG-IMRT. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found with IMRT, often full dose can be delivered to the target, while minimizing 
dose to the normal organs. IMRT can be considered necessary when a 3D plan is unacceptable and the IMRT 
plan results in a clinically meaningful reduction in normal tissue dose-volume delivery and/or improved target 
coverage. In general, there is no evidence basis to use >35 fractions at 1.8 gray (Gy) per fraction nor the use of 
multiple cone downs, especially when using IMRT that allows dose painting. The appeal letter does not really 
provide any rationale for using 1.8 Gy fractions, the result of which is simply to prolong treatment without any 
known or accepted benefit. The appeal letter states that 1.8 Gy fractions were chosen to spare uninvolved lung, 
which does not make sense and not supported by any evidence or guidelines. The decision is unfavorable for 
the additional fractions beyond the 34 that were approved, which adheres to National Comprehensive Cancer 
Network (NCCN) guidelines and American Society of Clinical Oncology (ASCO) Guidelines, as treating 41 
fractions with IMRT for stage III non-small cell lung cancer (NSCLC) is not an accepted standard of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional fractions of IG-IMRT have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) additional fractions of image-guided, intensity-modulated 
radiation therapy (IG-IMRT) (G6002, G6015, 770014).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (87636) provided on December 17, 2022. 
 
You asked the Plan to pay for 87636. You say that this service was medically necessary. The Plan denied your 
request. The Plan says this test was not billed with the required DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic tests must be billed with the 
appropriate DEX Z-Code adjacent to the procedure code in the comment/narrative field.  
 
We looked at the file and Medicare rules. This test code was not billed with the appropriate DEX Z-Code 
identifier. Based on this information, we decided that Medicare rules for coverage of 87636 have not been met. 
Therefore, we decided that the Plan does not have to pay for COVID-19 testing (87636) provided on December 
17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you do not have anyone around you to help 
you with transportation. You say that you need additional transportation to get to your doctor appointments and 
groceries. The Plan denied your request. The Plan says additional trips beyond the benefit allowance are not 
covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87426 billed for 
March 23, 2023. 
 
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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order 
to receive reimbursement from Federal programs.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct CLIA 
number. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with code 
87426 billed for March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a group 1 standard power wheelchair (K0813). 
 
You asked the Plan to pre-approve a group 1 standard power wheelchair. You say that you did not provide the 
additional information needed to be approved for the electric wheelchair, and nobody assessed you for this. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the requested supplies in this case. Specifically, we found that no home assessment was 
performed and there is no standard written order given by your provider. Therefore, we decided that the Plan 
does not have to pre-approve  a group 1 standard power wheelchair (K0813).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Ozempic.  Benefits for Ozempic 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
January 10, 2023 and an x-ray provided on January 16, 2023. 
 
You asked the Plan to waive the copayment for the outpatient hospital services and the x-ray. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for outpatient hospital services and a $20 copayment for x-rays. 
 
 The enrollee has been asked to pay a $350 copayment for the outpatient hospital services and a $20 copayment 
the x-ray. These services fall within the outpatient hospital services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient hospital services provided on January 10, 2023 and an 
x-ray provided on January 16, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81455. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 81301 and 81194.  
 
You asked the Plan to pay for procedure codes 81455, 81301 and 81194 billed for date of service January 24, 
2023. You say that these services were necessary and are supported in the medical record. The Plan says that 
these codes are not supported as reported. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81455.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan cited a rule which does not apply to the state where this 
laboratory testing was actually performed. The state in question does not participate with the Molecular 
Diagnostics contractor (MolDX) or the MolDX program. Therefore, the rule used by the Plan does not apply in 
this case. The Plan has not provided any other reason for denial of this test. Therefore, we decided that the Plan 
has to pay for the services described by procedure code(s) 81455.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 81301 
and 81194. 
 
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 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 services described by procedure code(s) 81301 and 
81194. Our reviewer says that these codes are not supported for separate billing. Our physician reviewer found 
the laboratory report does not include documentation to support rationale for separate payment of these codes, 
and therefore modifier XU 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 services described by procedure code(s) 81301 and 81194 have not been 
met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
81301 and 81194. 
 
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 procedure code 87481 billed for date of service May 16, 
2023.   
You asked the Plan to pay for procedure code 87481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87481 is 5. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87481 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87481 billed for date of service May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Aspen Interspinous Device to L4-5 
(22612). 
 
You asked the Plan to pre-approve implantation of the Aspen Interspinous Device. You say that the enrollee is 
losing neurological functions. The Plan denied your request. The Plan says the clinical value and effectiveness 
of the Aspen interspinous device 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 implantation of the Aspen Interspinous Device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Aspen interspinous spacer is experimental. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Aspen Interspinous Device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve implantation of the Aspen Interspinous Device to L4-5 
(22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 10, 2023. 
 
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 February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator provided on April 25, 2022. 
 
You asked the Plan to pay for the Cala Trio nerve stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee did not meet criteria for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulation for the treatment of 
motor function disorders, such as multiple sclerosis has not been verified. 
 
We looked at the file and Medicare rules. Review of the file shows that the item at issue was for electric nerve 
stimulation. This device is not covered for the enrollee's motor disfunction. Based on this information, we 
decided that Medicare rules for coverage of the Cala Trio nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cala Trio nerve stimulator provided on April 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on April 3, 2023, billed with 
codes 99214, 92611, 74230, 72040, and 74240. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The service provided is a barium swallow 
study and includes the administration of a substance to the patient. As such, this is a non-covered service. 
Therefore, we decided that the Plan does not have to pay for radiological services provided on April 3, 2023, 
billed with codes 99214, 92611, 74230, 72040, and 74240.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76881 billed for date of service August 20, 
2021. 
 
You asked the Plan to pay for procedure code 76881. You say that the medical records prove that these services 
were performed. The Plan denied your request. The Plan says payment for code 76881 is bundled into payment 
for code 20611. 
 
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 76881 
is a column II code to column I code 20611. 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 76881 billed for date of service August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311) and back canes 
with push handles (K0108). 
 
You asked the Plan to pre-approve an electronic connection device and the back canes. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
enrollee's upper limb strength and function are adequate for the member to be able to control the power options 
using their own switches, which are included in the allowance of these power options. The Plan also says that 
the back canes and push handles are only for caregiver convenience, and do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection device and the 
back canes. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee does have use of the upper extremities 
and can operate and control the power options using the switches that are included in the basic wheelchair. 
There is not a medical need for the upgraded electronics. The requested back canes and push handles do not 
serve a medical purpose and are therefore, 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 an electronic connection device and the back canes have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection device (E2311) and 
back canes with push handles (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 21, 2023, and billed with codes 87798, 87653, 87641, and 87481. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on April 21, 2023, and billed with codes 87798, 87653, 87641, and 87481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 21, 2023.  
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for procedures performed 
in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not 
covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Medicare does not cover refractive procedures even 
when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99153 and 99152 provided on March 9, 
2023. 
 
You asked the Plan to pay for procedure codes 99153 and 99152. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Procedure code 99152 is not supported. 
The records do not document the presence of a trained observer. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99153 and 99152 provided on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 5, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 5, 2023.