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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 23, 2023, billed with 
codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
June 23, 2023, billed with codes 81432 and 81433.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services rendered from March 8, 2022, to April 5, 
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 that there is no documented face-to-face encounter. 
 
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. We find that  The Plan states that there is no valid face-to-face encounter for 
these services; however, the documentation is insufficient to support this determination. Full records for the 
entire dates of service at issue are not present and it does not appear that the Plan requested the records. It is 
unclear if a face-to-face encounter was provided without the full span of records. Therefore, we decided that 
the Plan has to pay for the home health services rendered from March 8, 2022, to April 5, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an Affinity skin substitute. 
 
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 medically necessary. Our physician reviewer found the records support that the requested 
Affinity skin substitute is needed to avoid an extensive surgical procedure. The services are medically 
necessary for the enrollee 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 been met. Therefore, we decided that the Plan has to pre-
approve an Affinity skin substitute.  
 
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 Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have a documented history of hypoglycemia. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for intraperitoneal procedures in upper abdomen 
including laparoscopy provided on April 29, 2022. 
 
You asked the Plan to pay for anesthesia for intraperitoneal procedures in upper abdomen including 
laparoscopy. You say that the claim was originally sent on June 2, 2022 electronically and that is within timely 
filing limit. The Plan denied your request. The Plan says the claim was untimely, and the submission did not 
meet the exception criteria guidelines outlined in 42 CFR Section 424.44.  
 
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 anesthesia for intraperitoneal procedures in upper abdomen including 
laparoscopy was not filed until June 23, 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 
anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy provided on April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on June 21, 2023. 
 
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no records of the chest x-ray have been received to support the services 
billed. The medical records include evaluation and management note for the billed date; however, do not 
include chest x-ray report. 
 
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 chest x-ray have been met. The 
case file is missing the chest x-ray report. Therefore, we decided that the Plan does not have to pay for a chest 
x-ray provided on June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-invasive cerebrovascular arterial 
studies provided July 21, 2023. 
 
You asked the Plan to waive the copayment for non-invasive cerebrovascular arterial studies. You say that the 
copayment should be zero. 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 $120 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $120 copayment for non-invasive cerebrovascular arterial studies. This service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 non-invasive cerebrovascular arterial studies provided July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, of 15-21 drug classes (G0482) 
provide June 8, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial as the coding 
and diagnosis are both approved by Medicare.  The Plan denied your request. The Plan says the documents do 
not support the services 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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 
stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including 
metabolite(s) if performed. 
 
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 laboratory service. Our reviewer says that the documents 
do not support the criteria for coverage in this case. Our reviewer found the documentation submitted was 
reviewed and does not meet criteria. The laboratory report describes urine drug testing, however method of 
testing was not included in documentation and therefore cannot be verified. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, of 15-21 drug classes (G0482) provide June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation (HFCWO) 
system. 
 
You asked the Plan to pre-approve a HFCWO system. 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 follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 HFCWO system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a high-frequency chest wall 
oscillation device is not medically necessary. Chronic obstructive pulmonary disease (COPD) is not a diagnosis 
for which Medicare covers the high-frequency chest wall oscillation device, because its benefit has not been 
established in the treatment of patients with this condition. 
 
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 HFCWO system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation (HFCWO) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test provided on June 27, 2023. 
 
You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan 
denied your request. The Plan says the item is not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 
test provided on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will not be accepted by a 
skilled nursing facility due to their need to be seen daily by a nephrologist to determine ongoing dialysis needs. 
You say the enrollee is unable to tolerate transportation for outpatient dialysis and has a percutaneous 
endoscopic gastrostomy (PEG) tube placement with need for ongoing fluid and electrolyte balance monitoring.  
The Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has had a deteriorating clinical course and is receiving intensive care 
with intravenous vasopressors. The enrollees condition is too unstable for transfer to an LTACH. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser services (S9986 LT, S9986 RT) provided from 
April 6, 2022, and April 20, 2022. 
 
You asked the Plan to pay for the laser services. You say that the provider did not give you the required 
itemized receipt and procedure codes until after timely filing. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laser services have not been met. Specifically, you signed a Notice of Exclusion from Health 
Plan Benefits stating these services are not covered. Therefore, we decided that the Plan does not have to pay 
for the laser services (S9986 LT, S9986 RT) provided from April 6, 2022, and April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracorporeal shock wave provided by a chiropractor on 
May 1, 2023, to June 24, 2023. 
 
You asked the Plan to pay for the extracorporeal shock wave. You say that this procedure is covered by your 
insurance so you should be reimbursed for the cost. The Plan denied your request. The Plan says this is not a 
covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the extracorporeal shock wave provided by a chiropractor on May 1, 2023, to 
June 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 You asked the Plan to pre-approve Avastin. 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. 
 
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 Avastin. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the plan prefers a trial of Mvasi or Zirabev 
which this enrollee has not had and there is no reason given why either of these could not be given as they are 
just as likely to be effective. In addition, with an estimated glomerular filtration rate (EGFR) mutation EGFR 
targeted therapy would be 1st line therapy. 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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmic biometry, the scanning computerized 
ophthalmic diagnostic imaging, and the office visit provided on July 11, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the vision services. You say that you are requesting reconsideration of the denial. 
The Plan denied your request. The Plan says the provider is out-of-network, and prior authorization was not 
obtained. 
 
 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 did not pre-approve the 
vision services. We found no exception that would require the Plan to pay for the vision services. Therefore, we 
decided that the Plan does not have to pay for the ophthalmic biometry, the scanning computerized ophthalmic 
diagnostic imaging, and the office visit provided on July 11, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from August 2, 2023, through 
August 29, 2023. 
 
You asked the Plan to pay for the medication. 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 pay for the self-administered drugs from 
August 2, 2023, through August 29, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on April 3, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that the 
immunization should be covered. The Plan denied your request. The Plan says the vaccine is not covered under 
Part B, but is listed on formulary as being covered under Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on April 3, 2023.  
 Benefits for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that you are in terrible pain and 
medication is not helping. The Plan denied your request. The Plan says there are not enough studies to show 
that Vertiflex Superion is safe and effective to treat back pain. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental, and more research is needed. 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.