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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 27, 2023, and billed with codes 87481, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on January 27, 2023, and billed with codes 87481, 87640, 87653, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 5, 2022, billed 
with codes 87481, 87500, 87641, 87652, 87653, 87798 and 87900. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. 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 a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a laboratory 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 laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
testing provided on October 5, 2022, billed with codes 87481, 87500, 87641, 87652, 87653, 87798 and 87900.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the underarm crutches (E0114) provided on April 7, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the crutches. You say that the supplies were medically necessary and were 
provided to the enrollee under a physicians prescription. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 the underarm crutches (E0114) provided on April 
7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) provided on April 6, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this claim should not be considered OON 
because the enrollee does not come to the lab. The Plan denied your request. The Plan says these services are 
not covered when provided OON. 
 
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 the laboratory services (88305, 88312) provided 
on April 6, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that the enrollee has suffered from chronic 
intractable low back pain. The Plan denied your request. The Plan says the sprint PNS system 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 the sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is the subject of ongoing clinical trials and is considered an experimental therapy. 
 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis (L1686) and a pelvic control (L2624) provided 
on March 8, 2023. 
 
You asked the Plan to pay for a hip orthosis and a pelvic control. You say that you have billed the items at 
issue correctly. 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 provided medical records do not discuss the items at issue. 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 a hip orthosis (L1686) and a pelvic control (L2624) provided on March 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultomiris. 
 
You asked the Plan to pre-approve Ultomiris. You say that the requested Ultomiris is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try methotrexate, azathioprine, cyclophosphamide, 
cyclosporine, mycophenolate mofetil, or tacrolimus for at least 12 weeks first. 
 
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 Ultomiris. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) 
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 Ultomiris have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ultomiris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for November 3, 2022. 
 
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 procedure code 99213-95 is not supported. 
 
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 99213-95 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter. 
 
We find that CPT code 99213-95 is not supported in the medical record. Specifically, the records do not show 
that a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system was performed to support the code with the -95 modifier. 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 procedure code 99213-25 billed for November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent of the genicular nerve. 
 
You asked the Plan to pre-approve the nerve destruction. You say that your provider refuses to do a knee 
replacement and is recommending this procedure to manage your knee pain. The Plan denied your request. The 
Plan says the request 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered investigational and are 
not medically necessary for the treatment of chronic knee pain. 
 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 pre-approve destruction by neurolytic agent of the genicular nerve.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proair HFA aerosol. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has chronic obstructive pulmonary 
disease. 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 Proair HFA aerosol.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Koya Dayspring Active Compression Garment System. 
 
You asked the Plan to pre-approve Koya Dayspring Active Compression Garment System. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 Koya Dayspring Active Compression 
Garment System. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has lymphedema for which has used 
compression stockings and exercise with limited results. This specific requested device has not as of yet been 
shown to be as effective or more effective than a standard compression pump device for lymphedema. Therefore, with insufficient supportive evidence available in current literature, the Koya Dayspring Active 
Compression Garment System will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Koya Dayspring Active Compression 
Garment System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
April 7, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. 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 83520 is: Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these are "not otherwise specified" codes. The provided medical record does not identify to which requested tests the codes at 
issue apply. Based on this information, we decided that Medicare rules for coverage of procedure codes 83520 
and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
83520 and 87798 billed for date of service April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 system. 
 
You asked the Plan to pre-approve a Life2000 system. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 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 a Life2000 system. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It 
is intended to be used during activity, and there is inadequate evidence that it is beneficial in the treatment of 
any chronic lung disease. 
 
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 Life2000 system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Life2000 system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit rendered on 
February 10, 2023. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
Review of the file shows that you received specialist services on February 10, 2023. You have been asked to 
pay a $45 copayment for these services. This item/service falls within the covered visit or consultation in an outpatient location with a specialist 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 copayment for 
the specialist office visit rendered on February 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network echocardiography (EKG) 
test provided on May 3, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network EKG. You say that you already paid a 
copayment that day and you should not owe anything else. 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 20% 
coinsurance for Medicare-covered diagnostic tests (i.e., EKG and EEG).  
 
The allowed amount of this test is $452.66, resulting in a coinsurance amount of $90.53 ($452.66 x 20% = 
$90.53). You have been asked to pay a $90.53 coinsurance for an in-network EKG. This item/service falls within the 
Medicare-covered diagnostic tests (i.e., EKG and EEG) benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for an in-network echocardiography (EKG) test provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service 
November 30, 2022. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 codes 83520 and 87798 are not supported in the medical record. Specifically, codes 83520 
and 87798 both represent a not otherwise specified code. A complete description of the not otherwise specified 
code was not included. The order/ lab requisition must include what laboratory test was ordered/requested in 
order to validate the not otherwise specified code billed. Therefore, the billed codes and units cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 83520 
and 87798 for date of service November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 21, 2022. 
 
You asked the Plan to pay for an office visit. You say that you feel this should be covered and processed 
through your insurance with the $20 copay. The Plan denied your request. The Plan says you must submit your 
claim to them within one year of the date you received the service, item, or Part B drug. 
 
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 an office visit was not filed until April 25, 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 pay for an office visit provided on January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies billed with codes B4199, 
B4224, B4220 for date of service November 11, 2022, to November 16, 2022. 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that you disagree with the Plan's denial. 
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 a valid proof of delivery for the supplies provided in this case. The documentation 
did not include an enrollee receipt or proof of delivery of the supplies on the billed dates of service. 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 parenteral nutrition supplies billed with codes B4199, 
B4224, B4220 for date of service November 11, 2022, to November 16, 2022.