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

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (scooter) 
(K0800). 
 
You asked the Plan to pre-approve a scooter. The Plan denied your request. The Plan says the power operated 
vehicle requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 scooter. Our reviewer says that the 
group 1 power mobility device or power scooter is not medically necessary. Our physician reviewer found you 
are noted to have coronary artery disease and atrial fibrillation. The clinical documentation indicates that you 
are ambulatory and can perform your daily activities. Our reviewer found that there is no indication of a history 
of falling or significant motor strength or range of motion deficits. There is no indication that you cannot use a 
cane or walker for assistance with mobility or propel a manual wheelchair. Our physician reviewer also found 
that there is a lack of information as to whether you can safely operate the requested group 1 power mobility 
device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 standard power operated vehicle (scooter) (K0800).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Eylea. 
 You asked the Plan to pre-approve Eylea. You say that Avastin is no longer working so a change in treatment is 
necessary. The Plan denied your request. The Plan says the Plan requires a trial of Byooviz before it will 
approve Eylea. 
 
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 Eylea. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Eylea. Our physician reviewer found the 
enrollee has not tried and failed Byooviz. The record does not show that this drug would likely be less effective 
and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Eylea.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 60699 for date of service May 25, 2023. 
 You asked the Plan to pay for procedure code 60699. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is missing required information. 
 
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 60699 is not payable as billed. Specifically, the claim submitted did not include the 
location where the service was rendered (item 32). Based on this information, we decided that Medicare rules 
for coverage of procedure code 60699 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 60699 for date of service May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder brace (L3960), provided on June 8, 2023. 
 
You asked the Plan to pay for a shoulder brace. You say that the item was medically necessary. 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 records do not indicate the enrollee has a need for a shoulder brace or that the enrollee was referred to this provider. 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 shoulder brace 
(L3960), provided on June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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. Our reviewer says that 
the requested Sprint PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure. It is the subject of ongoing 
clinical trials. Therefore, the reviewer found that the requested Sprint PNS is not medically reasonable and 
necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, billed with 
codes 87481, 87640, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the documentation supports the services 
rendered. 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 NGS panel was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, 
billed with codes 87481, 87640, 87651, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service May 9, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the guidelines were followed for the billing. The 
Plan denied your request. The Plan says the service is 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 code. 
 
We find that CPT code 99214-25 is not supported in the medical record. The records do not show that code 
99214 was a separately identifiable evaluation service from minor procedure code 97597. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99214-25 billed for date of service May 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for procedure code 36000. You say that this service should be paid. The Plan denied 
your request. The Plan says procedure code 36000 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on July 31, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D7880). 
 
You asked the Plan to pre-approve the dental service (D7880). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the dental service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
dental service (D7880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 26, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the billed panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on June 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on July 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 26720 
provided on May 30, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (99285) provided on 
July 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device rendered on June 2, 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 there is no face-to-face encounter with the ordering provider within six months. 
 
The Plan must follow Medicare rules. The rules say that cervical traction devices are subject to the face-to-face 
encounter requirement. 
 
We looked at the file and Medicare rules. The file shows that there is no documented face-to-face encounter 
with the prescribing physician for this item and that the enrollee's physician confirms they did not refer the enrollee for this item. 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 the cervical traction device 
rendered on June 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DCISionRT testing (0295U) provided on June 12, 2023. 
 
You asked the Plan to pay for the DCISionRT testing. You say that the test results assist providers is planning 
the treatment and predicting outcomes. The Plan denied your request. The Plan says that a review of the 
medical literature and clinical practice guidelines does not support the clinical utility of this testing of multiple 
biomarkers in someone with DCIS. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DCISionRT testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is compelling data that suggest DCISionRT can be clinically useful, though  
National Comprehensive Cancer Network (NCCN) panel lists were unanimous that it should not be 
recommended for routine use at this time. So arguably it could be considered for select patients, particularly 
those clinically at low risk who may have a genomic signature suggestive of high risk. This enrollee in fact had 
a very high DCISionRT score and did seem to have intermediate clincopathologic risks (age 49 and 
intermediate grade are intermediate risk factors and 6 mm is a low risk factor). As it is plausible that the 
DCISionRT score would impact decision making (and in retrospect, the score suggested a strong indication for 
radiation) it is plausible that it would be offered as an accepted standard of care for this specific enrollee, even 
if not appropriate for routine use. Thus, this testing was medically reasonable and necessary in this case. 
 
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 DCISionRT testing have been met. Therefore, we decided that the Plan has 
to pay for the DCISionRT testing (0295U) provided on June 12, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on June 29, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Tempus xF testing provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on July 10, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuro-psychological testing. 
 
You asked the Plan to pre-approve neuro-psychological testing. You say that you are appealing the denial. The 
Plan denied your request. The Plan says that the requested physician has training in Pain Management and is 
not qualified to perform the testing. Additionally, per LCD L34520, testing conducted when no mental 
illness/disability is suspected would be considered screening and would not be covered.  
 The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is considered medically 
necessary and may be covered under certain circumstances. 
 
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 neuro-psychological testing. Our 
reviewer says that based on LCD L34520, the request is not considered to be medically necessary or 
reasonable. Our physician reviewer found that the provider is not credentialed in the use of neuropsychological 
testing, including administration, scoring and interpretation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuro-psychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuro-psychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular 
supports, adjustable (L0180) provided May 18, 2023. 
 
You asked the Plan to pay for the cervical collar. You say that you have attached the supporting 
documentation. Please reprocess the claim. The Plan denied your request. The Plan says this item or service 
does not meet the criteria for the category under which it was billed.  
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the referring physician's office did not order a brace and denied 
referring the enrollee to this supplier for any durable medical equipment supplies. The medical records received 
with the appeal included a prescription, proof of delivery and physician records; however, the records do not 
indicate the enrollee requested a cervical collar or that the enrollee was referred to supplier. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 cervical collar have not been met. Therefore, we decided that the Plan does 
not have to pay for the cervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) 
provided May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular 
supports, adjustable (L0180) provided July 5, 2023.  
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. 
Please reprocess the claim.  The Plan denied your request. The Plan says the documentation does not support 
the billed service. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the medical records received included physician notes, a written order, 
and a delivery confirmation; however, there is no supporting documentation to include diagnosing, treating, or 
managing a clinical condition for which the item was ordered. The review has determined that the 
items/services at issue in this case are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the cervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) provided 
July 5, 2023.