Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the ventilator is being requested for bi-
level pressure made as a respiratory assist device. Medicare does not cover the ventilator for this use. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that during the covid pandemic, no referrals or 
authorizations were required. 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 office visit provided 
on April 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G2023) provided on February 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G2023 is not supported in the medical record. Specifically, per the 2022 Q1 CMS 
Clinical Laboratory Fee Schedule, the code was inappropriately billed with the QW modifier. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (G2023) provided on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 10, 2023. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 16, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. 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 81456 billed for date of service January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 21, 2023, billed with codes 
87532, 87502, 87503, 87486, 87496, 87634, 87581, 87801, 87150, 87541, 87498 and U0002. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the lab testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
June 21, 2023, billed with codes 87532, 87502, 87503, 87486, 87496, 87634, 87581, 87801, 87150, 87541, 
87498 and U0002.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 31, 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 modifier -26 is not appropriate for the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The services at issue are billed procedure codes 80069-26, 82553-26, 
82570-26, 83735-26, 84100-26, 84156-26, and 85025-26. The -26 modifier is not allowed for laboratory 
services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for denture adhesive purchased on March 15, 2023. 
 
You asked the Plan to reimburse for denture adhesive. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says claims must be submitted for reimbursement within 120 days of 
the purchase date. The Plan also said that the claim was received after 120 days, therefore, not reimbursable. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service.  
 
The record shows that a claim for denture adhesive was not filed until July 17, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to reimburse for denture adhesive purchased on March 15, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been going to this provider every 3 
months for years and you have ever had a problem with the claim. The Plan denied your request. The Plan says 
the provider has opted out of Medicare.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 12, 2023. 
 
You asked the Plan to pay for the home visit. You say that the enrollee was residing in a nursing facility and 
should not need authorization. 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 home visit provided 
on May 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vtama. 
 
You asked the Plan to pre-approve the medication. You say that Vtama is medically necessary. 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 Vtama.   
Benefits for the medication 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation services provided on December 12, 2022. 
 
You asked the Plan to pay for the observation services. You say that the services were coded correctly. 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 observation services 
provided on December 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that the requested injection is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step therapy 
requirements. 
 
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 the injections. Our physician reviewer 
found that the Plan requires a trial of Byooviz or Cimerli before they will approve Vabysmo. Our physician 
reviewer found that based on the medical records provided there is no indication that the enrollee has tried and 
failed the required drugs. Our physician reviewer found that there is no indication that the Plans required drugs 
would likely be less effective and/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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on April 12, 
2023, billed with code 74177. 
 You asked the Plan to pay for the CT scan. You say that code 74177 was not bundled, and medical records 
submitted support the claim. Therefore, code 74177-26 should be paid. The Plan denied your request. The Plan 
says payment for code 74177-26 is bundled into payment for code 74178-26. 
 
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 74177 
is a column II code to column I code 74178. 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 the computed tomography (CT) scan provided on April 12, 2023, 
billed with code 74177.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cataract surgery provided on 
May 03, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for an in-network cataract surgery. You say that this provider is in-
network and you should not have a copayment, 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 a $270 
copayment for outpatient hospital services. 
 
You have been asked to pay a $270 copayment for an in-network cataract surgery. This item/service falls 
within the outpatient hospital 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. However, since the allowed amount is less than the standard copayment, you 
only owe $ 245.20 The total you owe is $ ($245.20 copayment x 2 visits = $490.40). Therefore, we decided 
that the Plan does not have to waive the copayment for an in-network cataract surgery provided on May 03, 
2023, to May 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
May 24, 2023. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is certified by Substance Abuse 
and Mental Health Service Administration (SAMHSA). You also say that this should be reprocessed and paid. 
The Plan denied your request. The Plan says that this claim does not meet the opioid treatment program criteria 
for payment. 
 
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. Specifically, the Plan's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on May 
24, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary. 
The Plan denied your request. The Plan says there is nothing in the supplied documentation that supports the 
necessity of the 12 additional PT visit.  
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has been approved for 38 sessions of physical therapy and 
is currently performing a home exercise program with range of motion and strengthening exercises. The 
enrollee can independently perform transfers and ambulate with an assistance device. The enrollee can continue 
with the home exercise program for continued strengthening. Therefore, the 12 additional PT visits are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing (81551) provided on October 14, 
2022. 
 
You asked the Plan to pay for the ConfirmMDx testing (81551). You say that the provided ConfirmMDx 
testing was medically necessary.  The Plan denied your request. The Plan says the enrollee did not meet criteria 
for the provided ConfirmMDx 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 pay for the ConfirmMDx testing (81551). Our 
reviewer says that the enrollee did not meet criteria for the provided ConfirmMDx testing. Our physician 
reviewer found the enrollee is with elevated prostate-specific antigen (PSA). Prostate biopsy was performed on 
October 14, 2022, and pathology was benign. Pre-biopsy PSA was 5.13 and normal digital rectal exam (DRE) 
was documented. ConfirmMDx was ordered on the same day. The enrollee did not meet the conditions as laid 
out above to meet the eligibility to obtain ConfirmMDx testing at the initial biopsy. 
 
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 ConfirmMDx testing (81551) have not been met. Therefore, we decided that 
the Plan does not have to pay for the ConfirmMDx testing (81551) provided on October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the portable oxygen concentrator (E1390 
and E1392) x3 provided from February 20, 2023, to April 20, 2023. 
 
You asked the Plan to waive the coinsurance for the portable oxygen concentrator (E1390 and E1392) x3. You 
say that the enrollee did not need the items so they should not have to pay for them. 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). The enrollees contract with the Plan clearly says that your cost 
sharing for Medicare oxygen equipment coverage is a 20% coinsurance every month. The enrollee has been asked to pay a total of $102.21 for the portable oxygen concentrator (E1390 and E1392).  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 20, 2023 oxygen 
concentrator 
$125.61 20% $25.12 
February 20, 2023 Portable oxygen 
concentrator 
$44.76 20% $8.95 
March 20, 2023 oxygen 
concentrator 
$125.61 20% $25.12 
March 20, 2023 Portable oxygen 
concentrator 
$44.76 20% $8.95 
April 20, 2023 oxygen 
concentrator 
$125.61 20% $25.12 
April 20, 2023 Portable oxygen 
concentrator 
$44.76 20% $8.95 
TOTAL:    $102.21 
 
These items/services fall within the durable medical equipment (DME) and related supplies benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the portable oxygen concentrator (E1390 and 
E1392) x3 provided from February 20, 2023, to April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver transplant to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve a liver transplant to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says the provider is not contracted and services are available within the Plan's 
network of providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a liver 
transplant to be provided by an out-of-network provider.