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

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on April 06, 2023. 
 
You asked the Plan to waive the copayment for a mammogram. You say that you disagree with the 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 $75 
copayment for outpatient diagnostic tests/advanced imaging services. 
 
You have been asked to pay a $75 copayment for a mammogram. This item/service falls within the outpatient 
diagnostic tests/advanced imaging 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a mammogram provided on April 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
26, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve Prochlorperazine. You say that this is to supplement antiemetic therapy 
prior to chemotherapy. 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 Prochlorperazine.  
 
Benefits for Prochlorperazine 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 the Tempus xF liquid biopsy (81455) provided on February 
18, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you disagree with the denial. You cannot 
walk by yourself. The Plan denied your request. The Plan says the request is not medically necessary because 
the records show you do not have notes that say you are not able to complete one or more mobility related 
MRADLS in your home. In addition, the records do not say that you are unable to use a cane, walker, or 
manual wheelchair. 
 
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.  The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and there is 
no documentation to show your condition cannot be improved by a walker, cane or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, teeth (code 70310) provided on 
December 6, 2022. 
 
You asked the Plan to pay for radiologic examination, teeth. The Plan denied your request. The Plan says 
charges for dental related services are excluded from coverage under the member's 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 pay for radiologic examination, teeth. Our reviewer says that the requested radiologic examination, teeth is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee had modified barium swallow on December 6, 2022. 
The evaluation of the dentition or oral cavity is not a routine part of a modified barium swallow and should not 
be reimbursed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiologic examination, teeth have not been met. Therefore, we decided that the 
Plan does not have to pay for radiologic examination, teeth (code 70310) provided on December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vertical shock-reducing pylon feature described by code L5988. 
 
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 that the services are not medically necessary. 
 
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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records document the 
enrollee's K3 ambulation level and gives concrete reasons for the treatment plan specific to his high-level 
function as a line cook. The documentation supports that the vertical shock-absorbing pylon feature is 
reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a vertical shock-reducing pylon feature described by code L5988.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a service dog. 
 
You asked the Plan to pre-approve service dog. You say that you would benefit from a service dog. The Plan 
denied your request. The Plan says you do not meet the Plan's criteria for the service dog support benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The Plans rules say that a service dog support benefit may be covered if supporting 
documentation is given that identifies the enrollee as the owner who requires use of a service dog and the 
service being rendered as defined under the ADA. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Dogs are available 
to the general public and would be helpful even to those who are not sick or injured. Additionally, the Plans 
documentation requirements for the service dog support benefit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a service dog.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 69209 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for procedure code(s) 69209. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 5 for CPT code(s) 69209. This indicator 
identifies codes that describe services covered incident to a physician's service when they are provided by 
auxiliary personnel employed by the physician and working under his or her direct personal supervision. These 
services are not payable when they are provided to hospital inpatients or patients in a hospital outpatient 
department. Based on this information, we decided that Medicare rules for coverage of procedure code 69209 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 69209 billed 
for date of service March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 3, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 3, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479 and 81238.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 10, 
2022.   
You asked the Plan to pay for procedure code 99283. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99283 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99283 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99283 billed for date of service April 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for foam dressing (A6209) and gauze (A6219, A6402) provided on March 
16, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that you disagree with the denial and request 
reconsideration of the claim denial. The Plan denied your request. The Plan says that the requested procedure 
codes are an item or service that has no separate payment under the physician fee schedule. 
 
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. The Plan has not submitted a valid denial rationale for the items at issue. The 
Plans argument is based on the Physician Fee Schedule status indicator of P for the codes at issue. The 
definition of this status indicator states that if the item or service is covered as incident to a physician service 
and is provided on the same day as a physician service, payment for it is bundled into the payment for the 
physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to 
physician service.).  If the item or service is covered as other than incident to a physician service, it is excluded 
from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the 
Act.  
 
The records show that this is a durable medical equipment (DME) supplier requesting payment under the DME 
fee schedule. No argument was made to justify non-payment under the DME schedule. Therefore, we decided 
that the Plan has to pay for foam dressing (A6209) and gauze (A6219, A6402) provided on March 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of PAE is considered 
experimental in nature for the treatment of symptomatic benign prostatic hyperplasia (BPH). The most recent 
American Urological Association (AUA) guidelines do not recommend the procedure outside of a clinical trial 
setting. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (PAE).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 13, 2022. 
 
You asked the Plan to pay for physical therapy. You say that this was medically necessary. The Plan denied 
your request. The Plan says the only documented diagnosis is temporomandibular joint (TMJ) syndrome which 
is insufficient. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnosis of TMJ on a claim is insufficient and 
the actual condition or symptom must be determined. 
 
We looked at the file and Medicare rules. The sole diagnosis of TMJ is insufficient. Based on this information, 
we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pay for physical therapy provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for infusion services (96366) provided on December 15, 2022. 
 
You asked the Plan to pay for the infusion services (96366). You say that this service was medically necessary. 
The Plan denied your request. The Plan says that the records do not support the units 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. In this case, the CPT Code Manual definition of 
code 96366 is Intravenous Infusion, Each additional hour. 
 
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 infusion services (96366). Our reviewer says that the 
records support the code billed. Our reviewer found the documentation does support the billed units of 96366, 
as the flow sheet indicates that the pump was started at 08:10 and completed at 10:17. 
 
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 infusion services (96366) have been met. Therefore, we decided that the 
Plan has to pay for infusion services (96366) provided on December 15, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 21, 2022, 
through November 2, 2022. 
 You asked the Plan to pay for the home health services. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 21, 2022. The NOA was not received by the Plan until April 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from October 21, 2022, through November 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had open heart surgery and is unable 
to walk or get themselves in and out of a chair. The Plan denied your request. The Plan says an IRF admission 
is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 6, 2022, 
through June 4, 2022.  
 You asked the Plan to pay for the home health services. You say that this claim was correctly billed and should 
be paid.  The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 6, 2022. The NOA was not received by the Plan until July 29, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
May 6, 2022, through June 4, 2022.