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

 
We decided that the Plan does not have to pay for the drug testing provided on July 13, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. 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 drug testing 
provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675), provided on 
April 27, 2023, through May 24, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) 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 the pneumatic compression device (E0675), provided on April 27, 2023, through May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure code G0482. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the provided records 
support testing for greater than 21 drug classes. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0482 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0482 billed for date of service April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686) and addition (L2624), provided on 
April 25, 2023. 
 
You asked the Plan to pay for the hip orthosis and addition. You say that the items were medically necessary. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication these items were needed or ordered in the clinical documentation submitted. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686) and addition (L2624), 
provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
on April 27, 2023, through May 24, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
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 the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218) provided on April 27, 2023, through 
May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on July 27, 
2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. You say that these services were 
medically necessary. 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 home visit, and 
debridement of nails provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee needed services on a Sunday. 
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 laboratory services 
provided on March 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations (D0140) provided on June 12, 
2023, and June 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration of the denied 
claims. The Plan denied your request. The Plan says your benefit for the requested services has already been 
exhausted. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service March 16, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluations (D0140) provided on June 12, 2023, 
and June 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network acute inpatient stay 
provided on July 20, 2023, to August 02, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network acute inpatient stay. You say that you feel this 
charge is too high for an inpatient 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 5% 
coinsurance for inpatient hospital care. 
 
You have been asked to pay 5% coinsurance for an in-network acute inpatient stay. This item/service falls within the 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. You have been asked to pay $863.29 for this inpatient stay, which is less than 
the 5% of the total amount charged. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an in-network acute inpatient stay provided on July 20, 2023, to August 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that bone marrow aspirate is medically 
necessary. The Plan denied your request. The Plan says bone marrow aspirate is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft material. More 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (85025) provided on May 20, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 85025 is Blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the lab order provided shows 
the request was for a complete blood count without differential WBC count. Based on this information, we 
decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the 
Plan does not have to pay for lab testing (85025) provided on May 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis, and a bone scan. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and a bone scan. The Plan denied your 
request. The Plan says a CT scan of the abdomen and a bone scan are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan of the abdomen and pelvis 
and a bone scan. Our reviewer says that a CT scan of the abdomen and pelvis and a bone scan is not medically 
necessary. Our physician reviewer found that imaging should only be considered in patients with prostate 
cancer at high risk for metastatic disease. Therefore, a CT scan and bone scan are not medically reasonable and 
necessary in this case. 
 
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 CT scan of the abdomen and pelvis and a bone scan have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis, and a 
bone scan.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on June 1, 2023. 
 
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 that the claim was not billed with the required DEX Z-code. 
 
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. We find that The Plan states that the services require billing a DEX Z-code and 
reference Local Coverage Determinations (LCDs) L35160 and L35025; however, these LCDs are not valid for 
Part B Medicare for the state of Louisiana where the testing was performed. The Plan has not provided any 
documentation or binding Medicare rules to support that the testing is not payable as billed. Therefore, we 
decided that the Plan has to pay for the laboratory services rendered on June 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
July 25, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel rendered on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265 x 4) and surgical extractions (D7210 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that surgical extractions are required with bone 
replacement therapy. The Plan denied your request. The Plan says the procedure may be more accurately 
represented by another dental code, or the service is not a covered benefit under your dental plan. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the extractions were appropriately downgraded. Our physician reviewer found that the x-rays show severe 
bone loss around the teeth. Teeth numbers 9, 23 and 24 have a small amount of bone around them and are 
single root teeth. Due to the extent of bone loss on these teeth, surgical extractions are not medically reasonable 
or necessary. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage D4265 is not 
among those covered under this benefit. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265 x 4) and 
surgical extractions (D7210 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow brace (L3761) provided on May 17, 2023. 
 
You asked the Plan to pay for the elbow brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not indicate that the member was treated for elbow pain or was referred for an elbow brace. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the elbow brace (L3761) provided on May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on July 11, 2023. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the service was medically necessary. 
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 psychotherapy 
(90837) provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) rendered on June 7, 
2023. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. The file shows that there is no valid physician order for the CGM and 
the provider confirmed they did not order this item for the enrollee. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor (CGM) rendered on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and receiver. 
 
You asked the Plan to pre-approve the CGM and receiver. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 the CGM and receiver. Our physician 
reviewer found that the record does not indicate the enrollee is on insulin or has a history of problematic 
hypoglycemia. Criteria are unmet 
 
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 CGM and receiver have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849) provide on May 2, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not indicate that there was a need for a traction device or that the enrollee was referred to this provider. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the traction 
equipment (E0849) provide on May 2, 2023.