Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 81003 and 85027. We decided that the Plan does not 
have to pay for procedure codes 84155, 84520, 85014, 85018, 85049, 81000, 82947, 84132, 84295, and 82565.  
 
You asked the Plan to pay for procedure codes 84155, 84520, 85014, 85018, 85049, 81000, 81003, 82947, 
84132, 84295, 82565, and 85027 billed for date of service June 9, 2020. You say that you disagree with the 
Plans denial. The Plan says that payment for procedure codes 84155, 84520, 85014, 85018, 85049, 81000, 
81003, 82947, 84132, 84295, 82565, and 85027 is included in code 80053. 
 
We decided that the Plan has to pay for procedure codes 81003 and 85027.  
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We have confirmed that procedure codes 81003 and 85027 are NOT column II codes to column I code 80053. 
No other denial rationale for these two codes was provided. Therefore, we decided that the Plan has to pay for 
procedure codes 81003 and 85027.  
 
We also decided that the Plan does not have to pay for procedure codes 84155, 84520, 85014, 85018, 
85049, 81000, 82947, 84132, 84295, and 82565. 
 
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 codes 
84155, 84520, 82947, 84132, 84295, and 82565 are column II codes to column I code 80053. We have 
confirmed that code 81000 is column II codes to column I code 81003. We have confirmed that codes 85014, 
85018, and 85049 are column II codes to column I code 85027. Therefore, we decided that the Plan does not 
have to pay for procedure codes 84155, 84520, 85014, 85018, 85049, 81000, 82947, 84132, 84295, and 82565. 
 
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 pneumatic propulsion tire, any size (E2211) and an 
insert for pneumatic propulsion tire (E2213). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you disagree with the denial 
due to being paralyzed on your left side from a stroke. The Plan denied your request. The Plan says you were 
approved for a wheelchair and other accessories. The pneumatic tires feature is for outdoor use. The wheelchair 
comes with tires adequate for indoor use. Medicare covers equipment only when needed in 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 pre-approve pneumatic propulsion tire, any size (E2211) and an insert for pneumatic propulsion tire 
(E2213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and an esophagogastroduodenoscopy. 
 
You asked the Plan to pre-approve a colonoscopy and an esophagogastroduodenoscopy. You say that you want 
the Plan to approve the services. The Plan denied your request. The Plan says the provider is out of the Plan's 
service area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a colonoscopy and an esophagogastroduodenoscopy have not been met. Criteria are not met since 
there is no expected return to the Plan's service area. Therefore, we decided that the Plan does not have to pre-
approve a colonoscopy and an esophagogastroduodenoscopy.
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 extraction (D7210 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that you need these extractions in order to get 
dentures. The Plan denied your request. The Plan says these services are either not a covered benefit under your 
dental plan or the benefit has 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, the requested items or services are not 
among those covered under this benefit. Additionally, your benefit for surgical extractions was exhausted on 
authorization number 0044367141. 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 extraction (D7210 x 5).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive therapy to return 
home peacefully and that cannot be met at a lower level of care. The Plan denied your request. The Plan says 
the enrollee does not meet all the requirements for admission to the IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Afirma genomic sequencing classifier oncology (thyroid) testing. 
 
You asked the Plan to pre-approve Afirma thyroid testing. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested service is not 
medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare will reimburse Afirma services for enrollees with 
the conditions listed in the Medicare rules section of this letter. 
 
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 Afirma genomic sequencing classifier 
oncology (thyroid) testing. Our reviewer says that the requested service is medically reasonable and necessary 
in this case. Our physician reviewer found that the enrollee has a follicular thyroid lesion with atypia of 
unknown significance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Afirma genomic sequencing classifier oncology (thyroid) testing have been met. 
Therefore, we decided that the Plan has to pre-approve Afirma genomic sequencing classifier oncology 
(thyroid) testing.  
 
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 testing provided on February 6, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial.  The Plan denied 
your request. The Plan says the enrollee must use in-network providers for medical services. This is available 
by a provider in your network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthotic. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is experimental. 
 
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 the MyoPro orthotic. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient or that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthotic (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87636 for date of 
service January 18, 2023. 
 
You asked the Plan to pay for the laboratory services billed with code 87636. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with code 87636 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 87636 for date of service January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the Life2000 home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) which 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 19, 2023, to 
January 26, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
correct DRG was assigned as the diagnoses were correctly reported.  The Plan denied your request. The Plan 
says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, defined as 
metabolic encephalopathy. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the diagnosis code at issue is not 
supported by the medical records.  Our physician reviewer found the enrollee presented to the hospital with 
baseline dementia with dislodgement of a right nephrostomy tube following prostate resection for enlarged 
prostate. The Glasgow coma scale score was noted to be 14-15 with hyperkalemia. He was treated with 
antibiotics and fluids for urosepsis.  
 
There were insufficient mental status changes beyond the enrollee's baseline according to the documentation to 
confirm metabolic encephalopathy following initial treatment in the emergency department. Therefore, 
metabolic encephalopathy (G93.41) is not sufficiently supported in the documentation for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 19, 2023, to January 26, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 You asked the Plan to pre-approve Entyvio. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the step therapy requirements have not 
been met. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
required drugs Inflectra or Renflexis. Also, there is no documentation indicating that the Plan's required drug 
would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay $225.73 more for the inpatient international hospital services. We 
decided that the Plan does not have to pay for the international hospital services in full.  
 
You asked the Plan to pay in full for inpatient international hospital services provided on February 25, 2022, 
through March 9, 2022. You say that there is a large outstanding amount due for the emergency services 
provided.  The Plan says that the $24,774.27 that they have reimbursed is the appropriate amount according to 
your contract, as the $25,000 maximum allowance has been met.  
 
We decided that the Plan has to pay $225.73 more for the inpatient international hospital services.  
 
Medicare rules say that, generally, items and services provided outside of the United States are not covered. 
However, the Plan provides coverage for emergency care and urgent care received outside of the United States 
and its territories up to a maximum of $25,000 per calendar year. 
 
The file shows that the Plan determined that the services at issue were urgent/emergent in nature. They have 
made two separate payments towards reimbursement according to your Worldwide benefit for urgently needed 
services. The first reimbursement payment was of $17,987.77. The second payment reimbursement payment 
was of $6,786.50. This totaled $24,774.27. The Plan has not substantiated their denial reason that the maximum 
benefit allowance has been met. Therefore, we decided that the Plan has to pay $225.73 more for the 
international hospital services.  
 
We also decided that the Plan does not have to pay for the international hospital services in full. 
 
Medicare rules say that, generally, items and services provided outside of the United States are not covered. 
However, the Plan provides coverage for emergency care and urgent care received outside of the United States 
and its territories up to a maximum of $25,000 per calendar year. 
 
Once the Plan reimburses the $225.73 more that weve determined is due, the $25,000 maximum allowance for 
emergency and urgent care received outside of the United States will have been reached. Therefore, we decided 
that the Plan does not have to pay for the international hospital services in full. 
 
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 pre-approve a magnetic resonance imaging of the abdomen; without 
contrast (74183) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an MRI of the abdomen. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the records do not indicate that the 
enrollee has an emergent or urgent medical condition or is in need of specialized service(s) that are not 
available in the network. The enrollee has an HMO (Health Maintenance Organization) plan. There are in-
network provider(s) within a reasonable distance from the enrollee's location that can provide this service  
or item. 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a magnetic resonance imaging of the abdomen; without contrast (74183) to be provided by an out-of-network 
(OON) provider.