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

 
We decided that the Plan does not have to pay for procedure codes 82728 and 82746 billed for date of service 
February 21, 2023. 
 
You asked the Plan to pay for procedure codes 82728 and 82746. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 82728 is: Assay of ferritin. The definition of code 82746 
is: Assay of folic acid serum. 
 
We find that CPT codes 82728 and 82746 are not supported in the medical record. Specifically, the physician 
order provided in the case record does not order an assay of ferritin nor of folic acid serum. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 82728 and 82746 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 82728 and 82746 billed for 
date of service February 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (J0887, J2501, 90999) provided on 
June 1, 2023, to June 29, 2023. 
 
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 the 
rendering provider is not enrolled 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 home health services (J0887, J2501, 
90999) provided on June 1, 2023, to June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 device (x3 units). 
 
You asked the Plan to pre-approve a Life2000 device. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 a Life2000 device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Life2000 system is not 
medically necessary. The Life2000 system is not a true ventilator because it is not capable of providing full 
ventilatory support. It is intended to be used during activity, and there is inadequate evidence that it is 
beneficial in the treatment of any chronic lung disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Life2000 device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Life2000 device (x3 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for eye refraction on August 11, 2023.  
 
You asked the Plan to waive the cost share for eye refraction. You say that you feel it should be paid. 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 original Medicare 
doesnt cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
 
 
 
 You have been asked to pay a $50 cost share for eye refraction. This item/service falls within the vision care - 
Medicare covered 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 cost share for eye refraction on 
August 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scans provided on June 01, 
2023. 
 
You asked the Plan to pay for the computed tomography (CT) scans. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scans provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 7, 2023, through June 7, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit. Specifically, the Plans contract states that coverage is provided for a fitness 
membership through the Plans select fitness provider. However, in this case, you purchased a gym 
membership from an out-of-network provider.   
 
 
Additionally, the Plans contract states that enrollees receive $300 every three months on a Flex card that may 
be utilized for qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. Therefore, we 
decided that the Plan does not have to issue reimbursement for the health club membership provided from 
January 7, 2023, through June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation provided on June 06, 2023, to 
July 17, 2023. 
 
You asked the Plan to pay for the chiropractic manipulation. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulation provided on June 06, 2023, to July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation and management 
provided on May 09, 2023, to May 15, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation and management. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
for the evaluation and management provided on May 09, 2023, to May 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5513). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that your podiatrist has always 
submitted for this and you have had it previously authorized with no issue.  The Plan denied your request. The 
Plan says the enrollee does not meet criteria for coverage for diabetic shoes and inserts.  
 
The Plan follows Medicare rules. Medicare rules say that health plans must ensure that services are provided 
when 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 diabetic shoes and inserts. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found the documentation 
supports that you are a diabetic and have a diagnosis of peripheral neuropathy. While it is noted that you 
demonstrate calluses to your feet, there is no documented clinical findings of peripheral neuropathy other than 
a stated diagnosis of peripheral neuropathy. Furthermore, during the February 27, 2023 progress note, you 
advised that you just received a new pair of diabetic shoes and insoles less that one month ago. It is unclear 
why you would require a second pair of diabetic shoes and insoles. Medicare does not pay for diabetic shoes 
and insoles, more than one pair, every year.  
 
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 diabetic shoes and inserts have not been met. Therefore, we decided that the 
Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5513).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of peripherally inserted central venous catheter 
(PICC) and insertion of tunneled centrally inserted central venous catheter to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve insertion of peripherally inserted central venous catheter (PICC) and 
insertion of tunneled centrally inserted central venous catheter. You say that the services should be covered. 
The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
insertion of peripherally inserted central venous catheter (PICC) and insertion of tunneled centrally inserted 
central venous catheter to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 5, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the laboratory service provided on June 5, 2023, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 20, 2022, billed with 
codes 81216, 81298 and 81317. 
 
\You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
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 
August 20, 2022, billed with codes 81216, 81298 and 81317.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right shoulder arthroscopy with rotator cuff repair 
(29824, 29826, 29827, 29828). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for a complete rotator cuff tear or rupture of the right shoulder, right 
shoulder impingement, primary osteoarthritis of the right shoulder, and right shoulder bicipital tendinitis. She 
presented with pain in the arm resulting in numbness.   
 
 
The right shoulder exam reveals tenderness over the bicipital groove. Forward elevation is 170 with pain on 
return to neutral, external rotation is 70, and internal rotation is T12. Strength is 4+/5 in the supraspinatus and 
4/5 in the infraspinatus. There is pain with abduction. There is pain with the Neers impingement test. Speeds 
test is positive, Spurlings test is positive, and the Cross body adduction is positive. 
 
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Additionally, diagnostic imaging also corroborates severe 
acromioclavicular (AC) joint osteoarthritis in the shoulder. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested right shoulder arthroscopy with rotator cuff repair is not medically 
reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right shoulder arthroscopy with rotator cuff repair (29824, 29826, 29827, 29828).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each monthly rental of the defibrillator 
vest provided on February 16, 2023, to April 16, 2023. 
 
You asked the Plan to waive the coinsurance for each monthly rental of the defibrillator vest. You say that you 
had many problems with the vest. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each monthly rental of the defibrillator vest. This 
item/service falls within the durable medical equipment and related supplies 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. The amount you owe for each monthly 
rental is $602.82 ($3,014.09 allowed amount x 20% = $602.82). The total amount you owe is 1,808.46 
($602.82 coinsurance x 3 monthly rentals = $1,808.46). Therefore, we decided that the Plan does not have to 
waive the coinsurance for each monthly rental of the defibrillator vest provided on February 16, 2023, to April 
16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 26, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care provided on June 26, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for anti-reflective coating (V2750) provided on June 28, 
2023. 
 
You asked the Plan to reimburse for anti-reflective coating (V2750). You say that you are asking the Plan 
approve payment for the anti-reflective coating applied to your post cataract eyeglass lenses. The Plan denied 
your request. The Plan says the service is not covered under your contract under any normal circumstances. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard eyeglasses and lenses after cataract surgery. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one pair of eyeglasses after 
each cataract surgery that includes insertion of an intraocular lens. The Plan contract also says that covered 
eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are 
not covered (including, but not limited to, anti-reflective coating). Based on this information, we decided that 
the Plan's rules for coverage of anti-reflective coating (V2750) have not been met. Therefore, we decided that 
the Plan does not have to reimburse for anti-reflective coating (V2750) provided on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at a significantly increased risk for peri-surgical 
complications requiring an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, it is not evident 
that the admitting physician would expect that the enrollee's necessary hospital care would span two midnights 
with supporting documentation of the enrollees history and comorbidities, signs and symptoms, current 
medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.