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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 09, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you have not 
been charged a copayment for previous CT scans. 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 a $220 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $220 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 a 
computed tomography (CT) scan provided on March 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided at an outpatient hospital facility provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI) provided at an outpatient 
hospital facility. You say that the copayment applied is incorrect and you should be getting a refund of $92. 
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 a $225 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $225 copayment for a magnetic resonance image (MRI) provided at an 
outpatient hospital facility. This item/service falls within the outpatient diagnostic test 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 a magnetic resonance image (MRI) provided at an 
outpatient hospital facility provided on March 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an AAA screening procedure. 
 
You asked the Plan to pre-approve an AAA screening. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary 
because the enrollee is not included in a pertinent risk category. 
 
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 AAA screening. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Medicare recognizes the recommendations for AAA screening one time in males 65-75 
years of age with a smoking history or other predisposing factors. There is a lack of evidence for such coverage 
in female patients. 
 
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 AAA screening have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an abdominal aortic aneurysm (AAA) screening procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and cup holder (K0108). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and cup holder. 
You say that you would like the K0862 base, and all recommended components needed to meet the enrollee's 
current medical, mobility, and functional needs to be reconsidered. The Plan denied your request. The Plan 
says 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 also says the 
requested cup holder does not serve a medical purpose, and cannot be covered as this is not reasonable and 
necessary per Medicare 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, harness, 
expandable controller, and cup holder. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found an expandable controller is an 
electronic system that is capable of accommodating one or more additional features and can operate 3 or more 
powered seating options. Our reviewer also found that the requested electrical accessories are not medically 
necessary as the enrollee does have use of the upper extremity and can operate and control the power options 
using the switches that are included in the basic 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, expandable controller, and cup holder have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and cup holder (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve folding push handles, side guards, short tabs, and 
bracket sets for a manual wheelchair.  

You asked the Plan to pre-approve manual wheelchair accessories. You say that this is needed to preserve the 
enrollee's shoulder function. The Plan denied your request. The Plan says these components are either not 
primarily medical in nature or are primarily intended for use outside of the home. The rules say that for 
equipment to be covered, it must primarily serve a medical purpose. 
 
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 items at issue in this appeal are either for use outside of the home or primarily for the comfort/convenience 
of the enrollee. Although these wheelchair features may be helpful, neither Medicare nor the Plan covers 
equipment for use outside the home or when the equipment does not serve a primarily medical purpose. 
Therefore, we decided that the Plan does not have to pre-approve folding push handles, side guards, short tabs, 
and bracket sets for a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 20, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 18, 2022. 
 
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 claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on December 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27886 provided on September 28, 2022. 
 
You asked the Plan to pay for procedure code 27886. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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 27886 is not supported in the medical record. Specifically, this is an inpatient procedure 
with a status indicator of "C", but it was billed on an outpatient claim. Based on this information, we decided 
that Medicare rules for coverage of procedure code 27886 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 27886 provided on September 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 6 visits of physical therapy (PT). 
 
You asked the Plan to pre-approve the PT visits. You say that the services are medically necessary for the 
enrollee to return to the highest level of function realistically attainable and within the context of the disability.  
The Plan denied your request. The Plan says the enrollee can transition into a home exercise program.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 6 visits of physical therapy (PT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a Continuous Positive Airway Pressure 
(CPAP) device.  
You asked the Plan to pre-approve continued use of a CPAP device. You say that the requested continued 
coverage of the CPAP device is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for continued coverage of the CPAP device.  
 
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 continued use of a CPAP device. Our 
reviewer says that the enrollee does not meet criteria for continued coverage of the CPAP device.  Our 
physician reviewer found continued coverage of CPAP is not medically necessary because the enrollee is not 
using the device enough to be effective. This enrollee has a diagnosis of mild obstructive sleep apnea. The 
enrollee was seen in follow-up on November 22, 2022. The note indicates that the compliance report covering 
August 24 to November 21, 2022, showed use of the device on 56% of days.  Medicare minimum use criteria 
are at least 4 hours/day for at least 70% of days. 
 
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 CPAP device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued use of a Continuous Positive Airway Pressure (CPAP) device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the services requested are only supported once every three months unless 
the enrollee has signs or symptoms that suggest worsening disease.  
 
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 the CT scan. Our physician reviewer 
found a follow up CT scan of the chest was approved. The CT scan of the abdomen and pelvis is not medically 
necessary at this time as the last imaging was less than 3 months ago and was negative for malignancy. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have 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. You say that 
the group 3 power wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan 
says 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 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, harness, and 
expandable controller. 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 adequate strength to 
manage standard power drives. Our reviewer also found that an expandable controller is not medically 
necessary to meet the enrollee's needs. 
 
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 not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve KRAS (Kirsten rat sarcoma viral oncogene homolog), gene 
analysis; variants in exon 2 (81275) and KRAS, additional variants (81276).  

You asked the Plan to pre-approve KRAS gene analysis. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that next generation sequencing is covered under certain 
conditions. 
 
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 KRAS gene analysis. Our reviewer says 
that the services are medically necessary. Our physician reviewer found in this case, this is part of next 
generation sequencing of the fluid to analyze whether this is mucinous and decide whether you will need 
surgery. This is an incorporated part of the fluid test analysis of the pancreatic cyst. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of KRAS gene analysis have been met. Therefore, we decided that the Plan has to 
pre-approve KRAS (Kirsten rat sarcoma viral oncogene homolog), gene analysis; variants in exon 2 (81275) 
and KRAS, additional variants (81276).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiogram provided 
on February 08, 2023. 
 
You asked the Plan to waive the copayment for the transthoracic echocardiogram. You say that you have only 
had to pay an office visit copayment in the past. 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 a $150 
copayment for outpatient diagnostic radiology. 
 
You have been asked to pay a $150 copayment for the transthoracic echocardiogram. This item/service falls 
within the outpatient diagnostic radiology 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. However, since the allowed amount is less than the standard copayment, 
you only owe $101.23. Therefore, we decided that the Plan does not have to waive the copayment for the 
transthoracic echocardiogram provided on February 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant body: endosteal implant 
(D6010) provided on March 17, 2023. 
 
You asked the Plan to pay for the surgical placement of implant body. You say that you would like to appeal 
the claim in the amount of $2,929. The Plan denied your request. The Plan says your benefit for the surgical 
placement of implant body 1,000 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the surgical placement of implant body was exhausted on date of service January 6, 
2023. You had 3 dental visits. The first claim processed and used $342 of the $1,000 dental allowance. That 
left $658 of the remaining which was applied to your second dental visit that was processed ($342 + $658 = 
$1,000). Therefore, we decided that the Plan does not have to pay for a surgical placement of implant body: 
endosteal implant (D6010) provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 21, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and was reported 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
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 
October 21, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81334.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 27, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says Medicare guidelines clearly state that Medicare 
Advantage Plans may not make payment for services performed by providers who have opted out of the 
Medicare Program, with the exception of emergency and urgently needed services. 
 
  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 nursing 
facility care provided on December 27, 2022.