Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee requires a CGM to monitor their low 
sugars as they are symptomatic when this happens. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
September 24, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 
87641, 87651, 87653, 87661, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urine PCR (polymerase chain reaction) panel provided on September 24, 2022, billed with codes 87481, 
87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) provided on 
November 29, 2022. 
 
You asked the Plan to pay for the urine PCR panel. The Plan denied your request. The Plan says this testing 
should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 
87798) provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $40 more for the single vision lenses (V2100), polarization (V2762), and 
high index lenses (V2782) purchased on December 9, 2022. 
 
You asked the Plan to pay $40 more for the single vision lenses, polarization, and high index lenses. You say 
that it looks like your coverage should have provided $100 for lenses, but the claim only paid $60. You also 
say that you believe you are due another $40. The Plan denied your request. The Plan says that this claim 
processed correctly. The Plan also says the claim will not pay out the $100.00, it deducts it from the total retail 
price/submitted charge to come up with your remaining responsibility. 
 
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 offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the record only shows that the Plan paid $60 toward this 
purchase, and there is no documentation showing the $100 eyewear benefit has been exhausted. Write-offs and 
disallowed amounts are not benefits that are actually paid by the Plan. Based on this information, we decided 
that the Plan's rules for coverage of the single vision lenses, polarization, and high index lenses have been met. 
Therefore, we decided that the Plan has to pay $40 more for the single vision lenses (V2100), polarization 
(V2762), and high index lenses (V2782) purchased on December 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 and the half leg appliance billed with code E0673 for October 25, 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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) billed with code E0675 and the half leg appliance billed with 
code E0673 for October 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the take-home supply of methadone provided on January 23, 2023. 
 
You asked the Plan to pay for the take-home supply of methadone. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for the take-home supply 
of methadone provided on January 23, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. The records show that the enrollee was under inpatient status when 
the services in question were provided. As such, it is inappropriate to bill these services with an outpatient POS 
code. 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 on December 12, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 95927, 95908, 95937, and 95885. We decided that the Plan does 
not have to pay for code 95955.  
 You asked the Plan to pay for the services (95955, 95927, 95908, 95937, 95885) provided on July 12, 2021. 
The Plan says that the billed codes are not supported. 
 
We decided that the Plan has to pay for codes 95927, 95908, 95937, and 95885.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 for codes 95927, 95908, 95937, and 95885. Our reviewer says that the 
use of codes 95927, 95908, 95937, and 95885, is supported by the records provided. Our reviewer found that 
for code 95927, the documentation describes the somatosensory evoked potential test, and the results are in 
support. Code 95908 is supported with the documentation with the results of the nerve conduction velocity 
study. Code 95937 is supported with the documentation and results describing the train of four testing. Code 
95885 is supported as the electroencephalogram is properly documented and described. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95927, 95908, 95937, and 95885, have been met. Therefore, we decided 
that the Plan has to pay for codes 95927, 95908, 95937, and 95885, billed for July 12, 2021.  
 
We also decided that the Plan does not have to pay for code 95955. 
 
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 95955 is Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery). 
 
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 for code 95955. Our reviewer says that code 95955 is not supported by 
the records provided. Our reviewer found that this procedure was not performed during cardiac surgery. 
 
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 95955 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95955 billed for July 12, 2021. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller (K1024) and a 
non-pneumatic sequential compression garment (K1032). 
 
You asked the Plan to pre-approve a non-pneumatic compression controller and a non-pneumatic sequential 
compression garment. You say that the Dayspring device offers unique clinical benefits and allows the enrollee 
to consistently self-manage their chronic conditions at home. You say that the Dayspring device is approved by 
the Food and Drug Administration (FDA). You say that the Dayspring device provides many key elements of 
conservative therapy. The Plan denied your request. The Plan says a review of the current medical literature 
does not consider the Dayspring device to be standard medical treatment for the management of lymphedema. 
 
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 a non-pneumatic compression 
controller and a non-pneumatic sequential compression garment. Our reviewer says that the requested items are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in 
this case has bilateral leg swelling. They were diagnosed with lymphedema and were referred to physical 
therapy. The records show that the enrollee tried to apply a compression bandage but had difficulty and that 
compression stockings didn't fit. A request was made for a Dayspring device (non-pneumatic compression 
controller and a non-pneumatic sequential compression garment). A review of the supportive evidence for this 
specific device does not show sufficient benefit over standard of care devices (pneumatic sequential 
compression device). There was no recent documentation or physician statement describing the indication for 
this device over standard of care devices. 
 
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 non-pneumatic compression controller and a non-pneumatic sequential 
compression garment have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
non-pneumatic compression controller (K1024) and a non-pneumatic sequential compression garment (K1032).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain fused to noble metal (D2752) for 
tooth #4. 
 
You asked the Plan to pre-approve a crown. You say that you are requesting reconsideration for the denial of a 
crown for tooth #4. The Plan denied your request. The Plan says the submitted radiograph does not show the 
presence of tooth #4. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  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 crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation provided does not meet 
the criteria for coverage for a crown for tooth #4. This tooth is not present in the oral cavity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown-porcelain fused to noble metal (D2752) for tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on December 19, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
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 (PCD) and appliance provided on December 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that you cannot do physical therapy. The Plan denied 
your request. The Plan says the Plan requires a trial of Orthovisc, Synvisc, and Monovisc before it will approve 
Hyalgan. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our reviewer says that you do 
not meet criteria for a step therapy exception for Hyalgan. Our physician reviewer found you have not tried and 
failed the Plan's preferred drugs of Orthovisc, Synvisc, and Monovisc. The record does not show that these 
drugs would likely be less effective and or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Hyalgan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT 648 Solid Tumor Assay (81455) provided on 
November 26, 2022. 
 
You asked the Plan to pay for the Tempus xT 648 Solid Tumor Assay. You say that this test was medically 
necessary. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT 648 Solid Tumor Assay test is 
not FDA approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xT 648 Solid Tumor Assay have not been met. Therefore, we decided that the Plan does not have to pay for the 
Tempus xT 648 Solid Tumor Assay (81455) provided on November 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 18, 2022, billed with 
codes 84781, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 18, 2022, billed with codes 84781, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87641, 87651, 
87653, 87661, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA 1/2 (breast cancer 1 and 2) Analyses with CancerNext 
+ RNAinsight panel (81162) provided December 7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are dealing with breast cancer a second time 
around. The oncologist requested that you undergo BRCA testing, and you explained that you had the test in 
2009. You did not know that there was a Medicare guideline that limits testing to once in a lifetime. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria and the performed panel is not 
covered per the DEX Diagnostics Exchange Registry. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the testing has been previously performed. 
Also review of the DEX Diagnostics Exchange Registry lists the Ambry BRCA 1/2Analyses +RNAinsight is 
Not Covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for BRCA 1/2 (breast cancer 1 and 
2) Analyses with CancerNext + RNAinsight panel (81162) provided December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99490) provided on October 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery..  
 
We looked at the file and Medicare rules. Payment for the requested services (99490) is included in the global 
surgery payment for the procedure (20552) provided on the same date of service. 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 (99490) provided on October 4, 2022.