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

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87640, 87481, 87500, 87640) 
provided on December 10, 2022.  
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the tests were for screening purposes and are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (87481, 
87500, 87640, 87481, 87500, 87640) provided on December 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for residential substance abuse services provided from 
June 15, 2022, to July 13, 2022. 
 
You asked the Plan to reimburse you for residential substance abuse services. You say that you were advised 
that the services were covered. The Plan denied your request. The Plan says residential substance abuse 
services are excluded from coverage. 
 
The Plan contract says that residential treatment- treatment to prevent the reoccurrence of a condition such as, 
but not limited to eating disorder, alcohol addiction etc. is not covered under any condition. 
 
We looked at the file and the Plans rules. The file shows that residential treatment- treatment to prevent the 
reoccurrence of a condition such as, but not limited to eating disorder, alcohol addiction etc. is not covered 
under any condition. Therefore, we decided that the Plan does not have to reimburse you for residential 
substance abuse services provided from June 15, 2022, to July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you have had multiple 
repairs and adjustments made to this wheelchair. You say that due to the issues with the center of gravity you 
do not fit in this chair properly. You also say that you would appreciate a brand-new wheelchair altogether. The 
Plan denied your request. The Plan says the power wheelchair you own is under five years old and is not in 
disrepair or unable to be modified to meet your mobility needs. 
 The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement power wheelchair. have not been met. Specifically, the file does not support that 
your current wheelchair is irreparably damaged. The file also does not support that you have had the 
wheelchair for at least five years. Therefore, we decided that the Plan does not have to pre-approve a 
replacement power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) and full leg 
appliance from an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that there isn't a network provider within 50 miles of 
your home. The Plan denied your request. The Plan says the services are available from in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) and full leg appliance from an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 billed for date of service February 16, 
2023. 
 You asked the Plan to pay for procedure code 71046. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71046 is bundled into payment for code 
32555. 
 
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, we have confirmed that code 71046 
is a column II code to column I code 32555. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 71046 billed for date of service February 16, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 23, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hemodialysis procedure with single evaluation by a 
physician or other qualified health care professional rendered on August 26, 2022. 
 
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 billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 90935 is "Hemodialysis procedure with single evaluation 
by a physician or other qualified health care professional." 
 
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 not supported by the medical records. Our reviewer found that the procedure report does not 
include sufficient documentation to verify reporting hemodialysis procedure with single evaluation by a 
physician or other qualified health care professional. There is a more appropriate code to report for service 
provided. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for a hemodialysis procedure with single evaluation by a physician or other qualified health care 
professional rendered on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liquid nutrition (codes B4185, B4193, B4220, and 
B4224). 
 
You asked the Plan to pre-approve liquid nutrition. You say that the enrollee is on hemodialysis, and their fluid 
intake is limited. You also say that you are requesting a formulation of Intra-dialytic Parenteral Nutrition 
(IDPN) to provide the maximum amounts of the required amino acids while minimizing the volume infused. 
The Plan denied your request. The Plan says this request does not meet the Medicare or health plan coverage 
criteria. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that enteral nutrition (EN) exacerbates gastrointestinal tract dysfunction. 
 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 liquid nutrition. Our reviewer says that 
the enrollee does not meet the LCD criteria for coverage for liquid nutrition (codes B4185, B4193, B4220, and 
B4224). Our physician reviewer found the review has determined that enteral nutrition has not been considered 
and ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The 
enrollee does not have: (a) a condition involving the small intestine and/or its exocrine glands which 
significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. Our reviewer also found that the beneficiary does not have a permanent 
impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liquid nutrition have not been met. Therefore, we decided that the Plan does not 
have to pre-approve liquid nutrition (codes B4185, B4193, B4220, and B4224).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hysterectomy, vaginal colpopexy, and combined 
anteroposterior colporrhaphy (58262, 57283, 57260). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the treatment is not appropriate for the enrollee's condition.  
 
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 services. 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 documentation that the total hysterectomy, vaginal colpopexy, and combined 
anteroposterior colporrhaphy at issue in this case meet all Medicare criteria for medically reasonable and 
necessary for the enrollee. The provided records in this case consist of a tele-medicine visit with no documented physical examination documenting severity of the enrollee's prolapse or complications of the 
prolapse. Records do not document trial and failure of (or contraindication of) non-surgical methods for 
management of the prolapse (such as use of a pessary).  
 
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 pre-approve a total hysterectomy, vaginal colpopexy, and combined anteroposterior colporrhaphy 
(58262, 57283, 57260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that there is no 
other supplier that can provide the same prescribed device to the enrollee. The enrollee needs this specific 
device due to her specific chronic lymphedema condition. The Plan denied your request. The Plan says the 
enrollee must obtain services from in-network providers. The Plan also says they have contacted the in-network 
provider and they have an equivalent medical device. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652) and a segmental pneumatic appliance for use with pneumatic 
compressor, full arm (E0668) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of Ilumya have 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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of preferred drug Taltz and three of the following preferred drugs: Cimzia, Enbrel, Humira 
or Amjevita, Skyrizi, Stelara, Tremfya, before they will approve the requested drug. The case file does not 
contain documentation of trial and failure of the preferred drugs. The documentation does not support that the 
preferred drugs would likely be less effective and/or would likely have adverse effects for the enrollee 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs orthotics for back pain. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the a continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a continuous glucose monitor is covered when 
medically necessary and all coverage criteria have been met. 
 
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 a continuous glucose monitor. Our 
reviewer says that the requested continuous glucose monitor is not medically necessary. Our physician 
reviewer found the records do not show that the enrollee uses insulin. The records do not describe any reason a 
standard glucometer cannot be used. The records do not show any hypoglycemic events. 
 
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 a continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Motegrity 2 mg. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed other 
medications and has only had relief with Motegrity. 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 Motegrity 2 mg.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that you want the Plan to approve this service. The 
Plan denied your request. The Plan says the requested service is not reasonable and necessary as the enrollee 
has no indications for a follow up sleep study. 
 
The Plan follows Medicare rules. 
 
   
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 sleep study. Our reviewer says that 
the requested service is not medically necessary. Our physician reviewer found this enrollee has known severe 
obstructive sleep apnea, on CPAP, and asthma. At a recent visit with her pulmonologist on March 15, 2023, the 
obstructive sleep apnea (OSA) was well controlled, and the enrollee was compliant with CPAP, with an 
Epworth sleepiness score of 3. There is no mention of a need for a sleep study. The diagnostic polysomnogram 
is not medically necessary because this enrollee is known to have obstructive sleep apnea and is doing well on 
current treatment. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99205, 95911, and 95886 rendered on 
November 22, 2022. 
 
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 services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 not supported by the medical records. Our reviewer found that CPT 99205 cannot be verified, 
the documentation does not support a high level of decision-making. In terms of CPT 95911, the procedure 
report does not support that 9-10 studies were performed. 
 
Additionally, CPT 95886 is not supported, as it is an add-on code that did not have an appropriate primary code 
billed on the same claim. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99205, 95911, and 95886 rendered on November 22, 2022.