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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 22, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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. This claim 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 May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on May 23, 2023. 
 
You asked the Plan to pay for the acupuncture. The Plan denied your request. The Plan says the acupuncture 
benefit is not covered when solely provided by an independent acupuncturist. 
 
The Plan must follow Medicare rules. Medicare rules say that an Acupuncturist is not eligible to participate in 
the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is an Acupuncturist. Medicare says 
that an Acupuncturist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan 
does not have to pay for acupuncture provided on May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 4, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these services do not require authorization 
or a referral per Medicare. The Plan denied your request. The Plan says non-emergent, non-urgent services with 
out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for wound care supplies provided on April 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections for electrostimulation therapy (codes J3420 
and J1955) provided on April 27, 2023. 
 
You asked the Plan to pay for the injections for electrostimulation therapy. The Plan denied your request. The 
Plan says the clinical value and effectiveness of electrical cell stimulation with injection of levocarnitine and 
cyanocobalamin in the setting of bilateral lower extremity and right knee pain due to osteoarthritis of the knee 
has not been demonstrated in the peer-reviewed literature. 
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injections for electrostimulation therapy. 
Our reviewer says that this request is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of lower extremity pain. The FDA has not stated that the requested 
drug is indicated for the enrollee's condition. Our reviewer also found that the Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the 
requested service cannot be recommended. 
 
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 injections for electrostimulation therapy have not been met. Therefore, we 
decided that the Plan does not have to pay for the injections for electrostimulation therapy (codes J3420 and 
J1955) provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection. 
 
You asked the Plan to pay for  the injection. The Plan denied your request. The Plan says the facet joint 
injection 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 pay for the injection. Our reviewer says that the 
facet joint injection is not medically necessary. Our physician reviewer found that the enrollee has multiple 
vertebral body fractures. The LCD criteria requires that there are no other probable pain generators, therefore 
the procedure is not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for  the facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional routine-transportation one-way trips. 
 
You asked the Plan to pre-approve additional trips. You say that the requested services are a necessity for your 
care. The Plan denied your request. The Plan says you have exhausted the routine-transportation benefit for the 
year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 72 additional routine-transportation one-way trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on 
September 15, 2022, to May 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for SNF services. You say that the provider has no knowledge of who they see in a 
facility. The Plan denied your request. The Plan says there is no prior authorization on file for the services 
provided. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on 
September 15, 2022, to May 18, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan with CT scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. You say that the enrollee had back surgery in 
2015 and need the requested PET scan. The Plan denied your request. The Plan says that a PET scan with CT 
scan is not medically necessary.  
 
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 scan with CT scan. Our reviewer 
says that a PET scan with CT scan is medically necessary. Our physician reviewer found that the enrollee has 
irregular 7mm left upper love nodule as well as elevated carotid endarterectomy (CEA). Therefore, the request 
is medically reasonable and 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 a PET scan with CT scan have been met. Therefore, we decided that the Plan 
has to pre-approve a PET scan with CT scan.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy and outpatient surgery on 
April 21, 2023.  
 
You asked the Plan to waive the cost share for chemotherapy and outpatient surgery. You say that you want to 
know why the amount is different from your last date of service. 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 all other Medicare-covered Part B drugs. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical centers services. You must pay a $260 copayment for Medicare-covered surgery or other 
services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility 
charges and physician or surgical charges. The provider billed in the amount of $1,015.00 and the allowed 
amount is $344.41 for the service. $344.41 x 20% = $68.88. The provider billed in the amount of $393.00 and 
the allowed amount is $69.86 for the service. $69.86 x 20% = $13.97. The provided billed in the amount of 
$93,315 and the allowed amount is $25,626.40. As only $1,938.40 left to reach enrollees out-of-pocket 
maximum. The provider billed in the amount of $142 and the allowed amount is $43.87. This is less than the 
copayment amount. For all services it's, $68.88 + $13.97 + $1,938.40 + $43.87 = $2,065.12. Therefore, results 
in the total cost sharing amount of $2,065.12. 
 
You have been asked to pay 20% coinsurance for chemotherapy and a $43.87 copayment, which is less than 
the copayment for outpatient surgery. This item/service falls within the Medicare Part B prescription drugs and 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 cost share for chemotherapy and outpatient 
surgery on April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring active compression garment system 
(K1024, K1033). 
 
You asked the Plan to pre-approve the Koya Dayspring system. You say that please review the attached records 
and clinical evidence to reconsider the decision to deny coverage. The Plan denied your request. The Plan says 
this item is considered experimental and investigational as there is insufficient evidence in its efficacy.  
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Koya Dayspring system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Koya Dayspring active compression garment system (K1024, K1033).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) and validity testing (83789) services 
provided on March 28, 2023. 
 
You asked the Plan to pay for drug testing and validity testing. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also 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 validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. We also decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of drug testing have been 
met. Specifically, the provided physician order does not clearly document the testing to be performed. 
Therefore, we decided that the Plan does not have to pay for drug testing (G0480) and validity testing (83789) 
services provided on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae hypertrophic cardiomyopathy panel (81439) 
provided March 31, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the physician ordered genetic testing for the 
enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The Plan 
says this test is not covered by Medicare. 
 
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. Per DEX Diagnostics, the Invitae Arrhythmia and Cardiomyopathy Comprehensive Panel is not covered by Medicare. Per Medicare guideline Local Coverage Determination 
(LCD) MolDX: Biomarkers in Cardiovascular Risk Assessment L36523, denies coverage for all non-lipid 
biomarkers when used for CV risk assessment including but not limited to, biochemical, immunologic, 
hematologic, and genetic biomarkers for CV risk assessment regardless of whether ordered in a panel or 
individually. 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 the Invitae hypertrophic 
cardiomyopathy panel (81439) provided March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80061) provided on May 13, 2023. 
provided on May 13, 2023. 
 
You asked the Plan to pay for the laboratory services (80061) provided on May 13, 2023.. 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 the laboratory services 
(80061) provided on May 13, 2023. provided on May 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the copper testing (82525) and zinc testing (84630) provided 
on May 17, 2023. 
 
You asked the Plan to pay for the copper and zinc testing. You say that these tests were medically necessary. 
The Plan denied your request. The Plan says the enrollee does not have a covered diagnosis for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that copper and zinc testing is covered for the 
diagnoses listed in the rules section of this letter. 
 
We looked at the file and Medicare rules. In this case, the provided records do not show that the enrollee has a 
covered diagnosis for the requested testing. Based on this information, we decided that Medicare rules for coverage of the copper and zinc testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the copper testing (82525) and zinc testing (84630) provided on May 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve a GI tract imaging. You say that you would like the patient to be approved 
for a capsule endoscopy in order to complete their GI work up and rule out any occult GI bleeding. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a WCE is limited to those patients who have 
undergone upper GI endoscopy and colonoscopy and these tests have failed to reveal a source of bleeding. 
 
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 GI tract imaging. Our reviewer says 
that the patient does not meet the criteria for coverage. Our physician reviewer found the patient has not had a 
recent colonoscopy which would be the standard next step in work-up. Our reviewer also found that without a 
recent colonoscopy, the wireless capsule endoscopy is not medically indicated, and the patient does not have an 
indication or criteria to qualify for wireless capsule endoscopy. 
 
 
 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 GI tract imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a gastrointestinal (GI) tract imaging (91110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration for the 
denied services. The Plan denied your request. The Plan says you do not meet criteria for approval of the 
requested genetic testing. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that the provided records do not show that you were diagnosed with 
breast cancer under the age of 50, that you have close blood relatives that were diagnosed with breast cancer at 
age 50 years or younger, that you have triple-negative breast cancer, or that you are to be treated with a poly 
adenosine diphosphate-ribose polymerase (PARP) inhibitor. You do not meet criteria for the requested testing. 
The requested testing 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81479).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy injection. 
 
You asked the Plan to pre-approve Wegovy injection. You say that the medical records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says Medicare guidance says a 
subcutaneous injection (a shot under the skin) that can be self-administered is covered by the pharmacy (drug) 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug(s) you are requesting is considered a Part B drug. As a 
result, no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve 
Wegovy injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73020 billed for date of service May 4, 2023. 
 
You asked the Plan to pay for procedure code 73020. You say that 73020 should be paid as billed because the 
enrollee had multiple exams on this same date of service, and they are supported in the documentation. The Plan denied your request. The Plan says payment for code 73020 is bundled into payment for code 73030, 
which was billed by the same provider on the same date of 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, we have confirmed that code 73020 
is a column II code to column I code 73030. This claim 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 73020 billed for date of service May 4, 2023.