Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humulin R U-500. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Humulin R U-500.   
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service December 21, 2022. 
 
You asked the Plan to pay for code 99285. You say that you are resubmitting this claim with medical records. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 26, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 99285 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99285 billed for date of service December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is an approved procedure by 
Medicare and the enrollee meets all of the criteria to help improve her low back pain. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. The cause of back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extracranial arteries; complete bilateral 
study provided on January 29, 2023. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries; complete bilateral study. You say that 
you are not liable or have the authority to obtain authorization as your radiology physicians are classified as 
silent providers. The Plan denied your request. The Plan says that with the information the Plan has, the Plan 
cannot determine how the member came to the servicing provider or whether the services are medically 
necessary. 
 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the duplex scan of extracranial arteries; 
complete bilateral study have been met. Therefore, we decided that the Plan does not have to pay for a duplex 
scan of extracranial arteries; complete bilateral study provided on January 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
21, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test rendered on February 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested test is not reasonable and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that although next generation sequencing (NGS) is often indicated for metastatic non-small cell lung 
cancer there is no rationale on why this enrollee needs liquid Tempus xF done. The enrollee is stated to have a 
estimated glomerular filtration rate (EGFR) indicating prior NGS testing but no other clinical data is provided. 
The service is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus xF test rendered on February 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99203-25), injection (20550), betamethasone acetate 
and betamethasone sodium phosphate (J0702), and hand x-ray (73130) provided on January 31, 2023. 
 
You asked the Plan to pay for the services. You say that the service was medically necessary. The Plan denied 
your request. The Plan says that the fact that the enrollee is new to the provider is not sufficient alone to justify 
reporting an evaluation and management service on the same date of service as a minor surgical procedure. 
 
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 asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the records do not make it clear if the 
enrollee is truly a new patient. However, modifier -25 is adequate for this visit, as there was an evaluation and 
management performed prior to the injection being given. The record does not state that the enrollee only came 
into the clinic for the injection. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the office visit (99203-25), injection (20550), betamethasone acetate and betamethasone sodium phosphate 
(J0702), and hand x-ray (73130) provided on January 31, 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: 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 a home ventilator is not medically necessary. The enrollee does not have chronic carbon dioxide (CO2) retention, and therefore does not meet 
criteria for a respiratory assist device. In addition, Medicare does not cover a home ventilator when used at 
settings that can be prior provided with bilevel positive airway pressure (BiPAP).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on May 27, 2022, billed with 
procedure codes 74240, 74230, 92611, 72040, 70100, and 70310. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on May 27, 2022, billed with 
procedure codes 74240, 74230, 92611, 72040, 70100, and 70310.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the requested therapy is 
medically necessary. The Plan denied your request. The Plan says there is not enough evidence that this type of 
radiation therapy guidance is needed or effective for the enrollee's skin cancer. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or image 
guided radiation therapy (IGRT) for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general) 
is not necessary. The decision is unfavorable as billing for daily IGRT which would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service is 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 provided on February 10, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel provided on March 28, 2023, 
and billed with codes 87150, 87798, 87481, 87640 and 87653. 
 
You asked the Plan to pay for the urinary tract infection panel . You say that 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 urinary tract infection panel have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel 
provided on March 28, 2023, and billed with codes 87150, 87798, 87481, 87640 and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided from  
November 10, 2022, to November 26, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says with the information we have, we cannot determine 
how the member came to the servicing provider, or whether the services are medically necessary.  
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the subsequent nursing facility care 
have been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care 
provided from November 10, 2022, to November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. 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 July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
2, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you provided the services to the 
enrollee as per the physician's prescription. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on February 14, 2023, billed 
with procedure codes 74230, 72040, 70100, 70310, 71045 and 74240. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are not covered under portable x-ray provision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on February 14, 2023, billed 
with procedure codes 74230, 72040, 70100, 70310, 71045 and 74240.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services are payable by Medicare. The 
Plan denied your request. The Plan says insufficient information was provided to review this claim. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 29, 2023.