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

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on January 6, 2023, and billed with codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, and 
87653. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. 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 panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel 
provided on January 6, 2023, and billed with codes 87500, 87641, 87798, G0452, 87471, 87481, 87551, 87651, 
and 87653.
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 December 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. 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 
December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 29, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 billed for date of service December 2, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that only 11 drug 
classes are recognized. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Determination, LCD L36037, the Plan used in their 
decision to deny services includes a chart that illustrates parent drugs and their metabolites. Although the chart 
only list 11 drug classes, the LCD does state that the chart may not be totally inclusive of all drugs and 
metabolites. There are more than 11 drug classes that are able to be tested. The Plan has not offered any other 
rationale for denial. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
procedure code G0483 billed for date of service December 2, 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visit. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says that 10 additional 
physical therapy visits are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visit. Our reviewer 
says that 10 additional physical therapy visits are medically necessary. Our physician reviewer found that the 
enrollee has previously been treated with outpatient therapies with improved range of motion. While the 
enrollee continues to have a posterior shoulder contracture, their medical provider recommends continued 
therapy to treat the contracture. Therefore, the additional therapy is 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 physical therapy visit have been met. Therefore, we decided that the Plan has to 
pre-approve 10 additional physical therapy visits.  
 
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 Dexcom G6 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom CGM. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee takes Ozempic and metformin. The documentation does not support that 
the enrollee is having low blood glucose sugars. There is no documentation to support why a fingerstick meter 
would not suffice. Therefore, the documentation does not support that the enrollee meets criteria for the 
requested device. 
 
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 Dexcom CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 billed for date of service January 9, 
2023. 
 You asked the Plan to pay for the billed services. You say that the diagnosis code was correct per 
documentation. The Plan denied your request. The Plan says the diagnosis is incorrectly coded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 93970 was billed with primary diagnosis code I82.432. This diagnosis code has a code 
first note at the manifestation code. This code is not permitted to be used as a primary diagnosis code. Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93970 billed for date of service 
January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive PGX Panel and Comprehensive Cardio 
Panel provided on September 23, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81335, and 81238. 
 
You asked the Plan to pay for the Comprehensive PGX Panel and Comprehensive Cardio Panel. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says this test should be billed 
with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Comprehensive PGX Panel and Comprehensive Cardio Panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the Comprehensive PGX Panel and Comprehensive Cardio Panel provided on September 23, 2022, and billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238.
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 September 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate.  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 
September 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 5, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 is a column II code to column I code 70496. Code 70450 has 
not been billed with an appropriate modifier to bypass the edit. 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 70450 
billed for date of service January 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computerized tomography (CT) scans identified with 
codes 74177 and 71260 for date of service September 30, 2022. 
 
You asked the Plan to pay for the CT scans. You say that you disagree with the Plan's denial. 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 November 4, 2022. 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 CT scans have not been met. Therefore, 
we decided that the Plan does not have to pay for the computerized tomography (CT) scans identified with 
codes 74177 and 71260 for date of service September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
22, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service 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 detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve the test strips. You say that you want to appeal this denial. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the supplies. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each radiation therapy service provided on 
August 05, 2022, to August 22, 2022. 
 
You asked the Plan to waive the coinsurance for each radiation therapy service. You say that you would like to 
appeal the coinsurance for these services. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network outpatient radiation therapy services. 
 
You have been asked to pay 20% coinsurance for each radiation therapy service. This item/service falls within 
the in-network outpatient radiation therapy 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 waive the 
coinsurance for each radiation therapy service provided on August 05, 2022, to August 22, 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 December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. 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 
December 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve Botox injections. You say that you have been seeing this provider for four 
years for your condition. You also say that this was denied because the provider is located in a different state. 
The Plan denied your request. The Plan says there are in-network providers that can provide the requested 
treatment.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 Botox injections. Our reviewer says 
that the request for the injections to be performed out-of-network is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee has Stiff Person Syndrome. The reviewer found that the 
plan has indicated that there are in network providers capable and available to provide the necessary care to the 
enrollee. The enrollee is receiving intermittent treatments that can be transitioned to an in network provider and 
can be transitioned to an in network provider at this time.  The record provided does not indicate the presence 
of any unique characteristics about this enrollees condition that would make it medically necessary for her to 
continue care with the out of network provider. Therefore, the reviewer found that the request for injections to 
be performed out-of-network is not 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 Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Botox injections to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve pneumatic compression device and appliance. You say that the NCD 
ensures coverage for people how have significant symptoms after the trial, regardless of improvement. The 
Plan denied your request. The Plan says recent notes were not received from the doctor that document the 
enrollee has been treated for lymphedema and that this device is medically necessary 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee is being treated for lymphedema and/ or chronic venous insufficiency 
with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve pneumatic 
compression device (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, full leg 
(E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess a self-administered drug. 
 
You asked the Plan to pre-approve Linzess. You say that the medication is medically necessary for the 
enrollees treatment for irritable bowel syndrome with constipation and they have tried and failed other 
medications. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess a self-administered 
drug.  
 
Benefits for Linzess may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ear, nose, and throat (ENT) visit provided on January 30, 
2023. 
 
You asked the Plan to pay for an ear, nose, and throat (ENT) visit. You say that this was medically necessary 
and 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 ear, nose, and throat 
(ENT) visit provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement pump (E0236), pad (E0249), and 
pneumatic compression device (E0650). 
 
You asked the Plan to pre-approve the items. You say that you need these items to be approved. You also say 
that you do not want to take pain medication. The Plan denied your request. The Plan says the requested items 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
for certain indications. The rules also say that a replacement pump or pad are not medically reasonable or 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the items have not been met. Specifically, the file shows that the items in this case are not being 
requested to treat lymphedema or a chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a replacement pump (E0236), pad (E0249), and pneumatic 
compression device (E0650).