Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contact lens fitting (92310), gas permeable contact lenses 
(V2512RT, V2512LT), and contact lenses (V2599) provided on February 1, 2023. 
 
You asked the Plan to pay for a contact lens fitting (92310), gas permeable contact lenses (V2512RT, 
V2512LT), and contact lenses (V2599). You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the benefit for this eyewear has been exhausted. 
 
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 reimburses up to $150 for these services every calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan offers a $150 reimbursement towards 
the purchase of eyeglasses or contact lenses every calendar year. The record shows the benefit was exhausted 
with this date of service. Based on this information, we decided that the Plan's rules for coverage of contact 
lens fitting (92310), gas permeable contact lenses (V2512RT, V2512LT), and contact lenses (V2599) have not 
been met. Therefore, we decided that the Plan does not have to pay for a contact lens fitting (92310), gas 
permeable contact lenses (V2512RT, V2512LT), and contact lenses (V2599) provided on February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service April 2, 2023, with the 
following codes: : 81225, 81226, 81227, 81231, 81232, 81240, 81241, and 81291. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says you should have billed these services with a 
single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported for the procedure. If there is no code that describes 
the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of 
service.   
 
 In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.  
 
We looked at the file and Medicare rules. 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 billed for date of service April 2, 2023, with the following codes: : 81225, 81226, 81227, 81231, 
81232, 81240, 81241, and 81291.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on April 13, 2023. 
 
You asked the Plan to pay for genetic testing. You say that this is supported in the records. 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 genetic testing provided 
on April 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits x28 to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve physical therapy visits x28. You say that you do not agree with the denial of 
the requested services. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
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 
physical therapy visits x28 to be provided 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 February 15, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe this claim was billed 
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 
February 15, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, and 
81328.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 6, 2022.  
 
You asked the Plan to pay for the physical therapy services. You say that the records provided support that the 
services in dispute were medically necessary.  The Plan denied your request. The Plan says they do not cover 
charges for treatment of TMJ other than by an open cutting operation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. The rules also say that Medicare covers treatment for TMJ syndrome only when the condition or 
symptom is medical in nature. The treatment must also be medically 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 pay for the physical therapy services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found that the dentist ordering the 
treatment only documented a diagnosis of TMJ with no other condition or symptom reported. The records 
provided do not document a medical condition.  
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 05, 2023. 
 
You asked the Plan to pay for a facility visit. You say that the enrollee is in a facility and the facility should 
have obtained the prior authorization. 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 facility visit provided 
on April 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee could be treated with bi-level positive airway pressure (BiPAP). 
 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 home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found the submitted records 
show that there is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee may 
benefit from bi-level positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) during sleep, but Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Leqembi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this member is not enrolled in a CMS-
approved clinical trial or NIH-supported trial for this drug. The review has determined that the documentation 
does not support that the Leqembi is medically reasonable and necessary or safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95873 billed for date of service February 10, 
2023.  
 
You asked the Plan to pay for procedure code 95873. You say that you believe this code is separately payable. 
The Plan denied your request. The Plan says payment for code 95873 is bundled into payment for code 95874. 
 
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 95873 is a column II code to column I code 95874 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95873 billed for date of service February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on April 7, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you are 
requesting reconsideration and have submitted medical records for review. The Plan denied your request. The 
Plan says the PCD was billed for use outside of the home and is not separately payable. 
 
 The Plan must follow Medicare rules. Medicare rules say that a PCD is covered in the home setting when 
medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency 
with venous stasis ulcers.  
 
We looked at the file and Medicare rules. The records show you billed with a place of service 24, which is an 
ambulatory surgical center, and is not considered a home. Based on this information, we decided that Medicare 
rules for coverage of a pneumatic compression device and an appliance have not been met. Specifically, 
Medicare rules say that a PCD is covered in the home setting for the treatment of lymphedema and chronic 
venous insufficiency (CVI) of the lower extremities. Therefore, we decided that the Plan does not have to pay 
for a pneumatic compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg 
(E0673) provided on April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service April 3, 2023, with the 
following codes: 81225, 81226, 81227, 81231, 81232, 81241, 81291, 81306, 81306, 81328, 81335, 81479, and 
81238. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you should have submitted either a single code or 
a panel code for these lab services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported for the procedure. If there is no code that describes 
the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of 
service.  
 In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.  
 
We looked at the file and Medicare rules. 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 billed for date of service April 3, 2023, with the following codes: 81225, 81226, 81227, 81231, 81232, 
81241, 81291, 81306, 81306, 81328, 81335, 81479, and 81238.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonsetron HCL. 
 
You asked the Plan to pre-approve Palonsetron HCL. 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 Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Palonsetron HCL. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found Palonsetron is being used as the 
antiemetic. This is a low emetogenic potential regimen and palonsetron is FDA approved for the prevention of 
acute and delayed nausea and vomiting associated with initial and repeat courses in adults treated with moderately emetogenic cancer chemotherapy and the prevention of acute nausea and vomiting associated with 
initial and repeat courses in adults treated with highly emetogenic cancer chemotherapy. This criterion is not 
meet and there is no off-label indications. The service was not reasonable or 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 Palonsetron HCL have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Palonsetron HCL.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0315U billed for date of service February 27, 2023. 
 
You asked the Plan to pay for code 0315U. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is not documented in the records. 
 
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 0315U is oncology (cutaneous squamous cell carcinoma), 
mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-
fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, 
Class 2B). 
 
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 code 0315U. Our reviewer says that this code is not 
supported for the billed date of service. Our reviewer found the laboratory report documents the collection date 
for the tested specimen as October 04, 2022, the received date for the specimen as October 10,2022, and the 
reported date for the testing as October 11, 2022. There is no documentation of testing performed on the billed 
date of service, February 27, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 0315U have not been met. Therefore, we decided that the Plan does not 
have to pay for code 0315U billed for date of service February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035). 
 
You asked the Plan to pre-approve a custom breast prosthesis. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for the additional features 
of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been 
established and will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a custom breast prosthesis have not been met. Specifically, the requested breast prosthesis is not 
covered by Medicare or the plan. Therefore, we decided that the Plan does not have to pre-approve a custom 
breast prosthesis (L8035).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on March 03, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you should not 
have to pay the copayment because you did not receive assistance from the provider. 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 $90 
copayment for Emergency Care. 
 
You have been asked to pay a $90 copayment for each emergency room (ER) visit. This item/service falls 
within the Emergency Care 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 each 
emergency room (ER) visit provided on March 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001RR). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the item is necessary. The Plan denied 
your request. The Plan says the enrollee received a wheelchair September 20, 2022. The enrollee's current 
equipment is less than 5 years. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a standard wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a standard wheelchair (K0001RR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 28, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided on March 8, 2023.