Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 25, 
2022. 
 
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 August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530) and the therapeutic 
exercises (97110) provided from July 27, 2021, through September 23, 2021. 
 
You asked the Plan to pay 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 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 services at issue are not covered by Medicare or the Plan. Therefore, we decided that 
the Plan does not have to pay for the therapeutic activities (97530) and the therapeutic exercises (97110) 
provided from July 27, 2021, through September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 for 
November 11, 2022. 
 
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 services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the surgical pathology services billed with code 88305 for November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says that this service is not covered when received by an out-
of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan contract also says that the enrollees POS benefit does 
not apply to out-of-network lab services. 
 
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 services provided on October 13, 
2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87798) provided on 
November 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the enrollee requested for the toenail to be 
tested for fungus and to be treated as the infection is getting worse. Enclosed are the medical records to support 
the service billed. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 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 services (87481, 87798) provided 
on November 15, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography (77063, 77067), provided on December 7, 
2022. 
 
You asked the Plan to pay for the mammography. You say that the service should be covered. The Plan denied 
your request. The Plan says this benefit has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that for a woman over 39, Medicare pays for a 
screening mammography performed after 11 full months have passed following the month in which the last 
screening mammography was performed. To determine the 11-month period Medicare starts counting 
beginning with the month after the month in which a previous screening mammography was performed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mammography have not been met. Specifically, the documentation submitted indicates you received this services in January of the same year. Therefore, we decided that the Plan does not have to pay for 
the mammography (77063, 77067), provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 2022. 
 
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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99441 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 99441. You say that the service at issue was billed 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 99441 is: Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 We find that CPT code 99441 is not supported in the case record. Specifically, the Plan has documented that a 
related evaluation and management service was billed within the previous 7 days of the date of service at issue 
in this case. Based on this information, we decided that Medicare rules for coverage of procedure code 99441 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99441 billed 
for date of service June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on October 16, 2022. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. 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 lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
October 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) fractions of Stereotactic Body Radiation 
Therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee would benefit from SBRT, and you have 
included a 3D comparison chart and clinicals. The Plan denied your request. The Plan says treatment is not 
reasonable and necessary under Medicare guidelines. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT, delivering high fractional doses in 3-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. This enrollee has untreated more widespread disease and the clinic 
note explicitly describes the treatment as palliative. While SBRT for oligoprogression is an emerging treatment 
the case records do not justify the need for SBRT (or 5-fraction IMRT per the original request). Given multi-
focal nature of the disease, the decision is unfavorable as SBRT for clinically diagnosed sarcoma would not be 
standard in the setting of multifocal disease for which only 1 lesion is to be treated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve five (5) fractions of Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86304) provided on December 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Tumor Antigen testing is covered only for 
specific diagnosis codes. 
 
We looked at the file and Medicare rules. Diagnosis codes C50.911, C79.51, Z17.0, and C50.919 are not listed 
as valid diagnosis codes for the testing billed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (86304) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
January 5, 2023. 
 
You asked the Plan to pay an additional amount for the eyeglasses. You say that you were told you would be 
reimbursed. The Plan denied your request. The Plan says the claim paid according to the benefit. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services one per calendar year.  
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the allowable amount. Therefore, 
we decided that the Plan does not have to pay an additional amoutn for eyeglasses provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you qualify for the benefit. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 31, 2022, 
through April 10, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says an itemized bill was requested multiple times and not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. 
Specifically, the documentation submitted does not include an itemized bill to verify the services. The record 
shows that the Plan requested this information, and it was not received. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care provided from March 31, 2022, through April 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry, interpretation (88188) provided on 
October 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached medical records 
supporting the medical necessity for the services provided. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 flow cytometry, interpretation (88188) 
provided on October 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent detection (87631) billed for date of service 
July 28, 2022. 
 
You asked the Plan to pay for infectious-agent detection. You say that the service at issue was billed correctly. 
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 infectious-agent 
detection have not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent 
detection (87631) billed for date of service July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a fall risk and requires medical and 
nursing supervision in an IRF setting. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one (1) injection, OnabotulinumtoxinA (J0585). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial. The Plan denied 
your request. The Plan says medical records submitted do not establish that the injection is reasonable and 
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 an injection. 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 a diagnosis of gastroesophageal reflux disease, irritable bowel syndrome and 
gastroparesis. Based on the medical records provided and the Medicare-approved major drug compendia there 
is no documentation that the Botox at issue in this case meets all Medicare and LCD criteria for medically 
reasonable and necessary for the enrollee. The Medicare-approved major drug compendia and the LCD do not 
support that gastroesophageal reflux disease, irritable bowel syndrome and gastroparesis are medically 
accepted indications for use of Botox. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve one (1) injection, OnabotulinumtoxinA (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee continues to need physician monitoring, 
meets criteria for medical necessity, and has functional limitations due to past admission and hospitalization. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from 
physical therapy, occupational therapy, and speech and language pathology, the enrollee's rehabilitation needs 
can be provided in a lower intensity and alternate setting such as in a skilled nursing facility or continued 
therapies at home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.