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

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87500, 87640, 87641, 87651, 
87798 and 87801) provided on September 13, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this test was a laboratory panel that was not 
billed with a single panel code as required by Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87500, 87640, 87641, 87651, 87798 and 87801) 
provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM system. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 CGM system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you are requesting an expedited appeal for the 
denial of a PET/CT scan. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the requested PET/CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that although the enrollee has a 
mediastinal mass, the current best practice would be to not perform a PET scan. The scan will not yield any 
diagnostic information. The enrollee does not have an indication for this PET scan. 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
May 20, 2023, to June 8, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for PCDs have not 
been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from May 20, 2023, to June 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530 and 97535 billed for date of service 
July 24, 2023. 
 You asked the Plan to pay for the billed services. You say that the records prove medical necessity. The Plan 
denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F02.A18. This 
code is not an appropriate primary diagnosis as diagnosis code group F02 has a Code first note indicating to 
code the underlying condition first, and the billed diagnosis code definition includes in diseases classified 
elsewhere which means it is a manifestation code. Based on this information, we decided that Medicare rules 
for payment of this claim have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 97530 and 97535 billed for date of service July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the device evaluation provided on June 19, 2023. 
 
You asked the Plan to pay for the device evaluation. 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 device evaluation 
provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 19, 
2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on August 09, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on August 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from June 9, 2023, to June 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says an NOA was not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that NOAs must be submitted timely. A timely-filed 
NOA is submitted to and accepted by the A/B MAC (HHH) within five calendar days after admission date. 
 
We looked at the file and Medicare rules. A timely NOA was not submitted in this case. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided from June 9, 2023, to June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the tissue transfer and lymph node removal 
and mapping provided on December 2, 2022, and the specialist office visit provided on December 8, 2022. You asked the Plan to reduce the cost share for the surgical services and the specialist office visit. You say that 
these services should have been processed at the in-network benefit level. 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 50% 
coinsurance for out-of-network surgical services and out-of-network specialist office visits. 
 
The record shows these services were provided by an out-of-network provider. Therefore, the out-of-network 
cost share was applied correctly. You have been asked to pay up to 50% coinsurance of the allowed amount for 
the out-of-network surgical services provided on December 2, 2022. These services fall within the outpatient 
surgery benefit category.  
 
You have also been asked to pay 50% coinsurance of the allowed amount for the specialist office visit on 
December 8, 2022. This service falls within the physician/practitioner services 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 reduce the cost share for the tissue transfer and lymph node removal and mapping provided on 
December 2, 2022, and the specialist office visit provided on December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the requested item is necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary fractional flow reserve by coronary computed 
tomography angiography (FFRct) (0501T). 
 
You asked the Plan to pre-approve FFRct. 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 follows Medicare rules. Medicare rules say that noninvasive fractional flow reserve deduced from 
computed tomography (FFRCT) involves computer-assisted processing of coronary computed tomography 
angiography (CCTA) images to estimate changes in blood pressure inside coronary arteries that have partial 
blockages, with the goal of determining how severely the blockages impede blood flow to the heart. 
 
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 FFRct. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found FFRct is based on computer-assisted 
processing of coronary CT angiography images to estimate coronary blood flow changes related to coronary 
artery stenoses. It is only performed if baseline CT angiography shows a borderline stenosis. He has 
claudication symptoms, but no change in cardiac signs or symptoms. As such, it would not appear that he is a 
candidate for FFRct. In summary, the requested testing is not considered 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 FFRct have not been met. Therefore, we decided that the Plan does not have to 
pre-approve coronary fractional flow reserve by coronary computed tomography angiography (FFRct) (0501T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech language pathology services described by code 
92507 performed on September 28, 2023. 
 
You asked the Plan to pay for 92507. You say that 92507 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 92507 is denied because the diagnoses billed do 
not meet Medicare National Coverage Determination (NCD) or Local Coverage Determination (LCD) criteria. 
 The Plan must follow Medicare rules. Medicare rules say that in order for CPT code 92507 to be covered, it 
must be reported with a diagnosis code that supports medical necessity. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the speech language pathology 
services described by code 92507 were billed with diagnosis codes R13.12, I69.354, and I50.9. Per LCA 
A54111, R13.12, I69.354, I50.9 are not listed as diagnosis codes that support medical necessity. Coverage of 
92507 is limited to only claims in which diagnosis codes determined by the LCA to support the medical 
necessity are reported. Based on this information, we decided that Medicare rules for coverage of 92507 have 
not been met. Therefore, we decided that the Plan does not have to pay for the speech language pathology 
services described by code 92507 performed on September 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
June 20, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that this was not an 
overnight stay. 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 $500 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $500 copayment for the inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital 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 reduce the copayment for 
the inpatient hospital stay provided on June 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient  hospital observation provided 
on August 08, 2023. 
 
You asked the Plan to waive the copayment for outpatient  hospital observation. You say that you were not 
even observed for 24 hours, you should not be responsible for this copayment. 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 $400 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $400 copayment for outpatient  hospital observation. This item/service falls 
within the outpatient hospital observation 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 outpatient  hospital observation provided on August 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided November 14, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided November 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol and/or substance abuse structured screening and brief 
intervention services provided from April 9, 2022, to May 7, 2022. 
 
You asked the Plan to pay for alcohol and/or substance abuse structured screening and brief intervention 
services. You say that your counselor advised you to go to a rehabilitation center and gave three names and he 
selected this facility. You say that you did not think about needing permission only that you needed help. The 
Plan denied your request. The Plan says this type of provider is not part of the Medicare program. 
 
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 alcohol and/or substance abuse 
structured screening and brief intervention services provided from April 9, 2022, to May 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 27, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records proving 
medical necessity. 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 laboratory services 
provided on June 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on August 09, 2023. 
 
You asked the Plan to pay for the mental health visit. 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 mental health visit 
provided on August 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 10, 2023. 
 
You asked the Plan to pay for the durable medical equipment. 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 durable medical 
equipment provided on March 10, 2023.