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

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 15, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
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 pharmacogenomics panel was not billed with a single code as required. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the gene panel testing provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the BRCA genes (81162). 
 
You asked the Plan to pre-approve BRCA testing. You say that you have a family history of cancer (lung and 
breast) and you are concerned for your health and that you may be carrying the gene. The Plan denied your request. The Plan says this test would be considered a screening as you have no personal history of diagnosis of 
cancer and is considered non-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 rules say that hereditary cancer tests are only 
covered in patients with a cancer diagnosis who also meet other specific criteria. 
 
The test at issue in this appeal, BRCA testing, is being requested solely for screening purposes as you do not 
have a personal history or diagnosis of any cancer. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pre-approve genetic testing for the BRCA genes 
(81162).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 16, 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 procedure codes 26123 and 26125 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. 
 
In this case, the CPT Code Manual definition of code 26123 is fasciectomy, partial palmar with release of 
single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, 
or skin grafting (includes obtaining graft). The definition of code 26125 is fasciectomy, partial palmar with 
release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue 
rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to 
code for primary procedure). 
 
We find that CPT codes 26123 and 26125 are not supported in the medical record. Specifically, there is no 
documentation of a partial palmar fasciectomy with release of a single digit to support code 26123. Given that 
primary procedure code 26123 is not supported, add-on code 26125 is also not supported. 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 surgical services rendered on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant maintenance procedure (D6080) and precision 
attachment (D5862) provided by a participating provider on April 23, 2022. 
 
You asked the Plan to pay for an implant maintenance procedure and precision attachment. You say that you 
were told that your implants would be covered. The Plan denied your request. The Plan says the rendered 
dental work 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 pay for an 
implant maintenance procedure (D6080) and precision attachment (D5862) provided by a participating 
provider on April 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92313) provided on May 24, 2022. 
 You asked the Plan to pay for the vision care. You say this service should be covered under your medical 
benefit as post-cataract surgery care. The Plan denied your request. The Plan says that contact lens fitting is not 
a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The Plan coverage does not provide a benefit for contact lens fitting. 
Based on this information, we decided that the Plan's rules for coverage of the vision care have not been met. 
Additionally, while the Plan covers cataract surgery and lenses after the surgery, the contact lens fitting would 
be considered routine in nature and thus not covered. Therefore, we decided that the Plan does not have to pay 
for the contact lens fitting (92313) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667x2). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that due to pressure issues, the 
enrollee could not complete the prior trial period needed. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested services as there is no documentation of a failed four-week 
trial. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667x2).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colorectal cancer screening (G0121). 
 
You asked the Plan to pre-approve the screening test. You say that the enrollee needs this. The Plan denied 
your request. The Plan says that that the enrollee is not at high risk for colon cancer. The Plan also says that the 
colorectal screening test is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a screening colonoscopy at a frequency of once every 
24 months for beneficiaries at high risk for developing colorectal cancer. An individual is considered to be at 
high risk for developing colorectal cancer when they have a personal history of adenomatous polyps. 
 
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 screening test. Our reviewer says 
that the requested colon cancer screening colonoscopy is medically necessary. Our physician reviewer found 
the record indicates that the enrollee underwent coloscopy in 2017 and one 7 mm adenomatous polyp was 
found and resected. The reviewer found that this is considered a high-risk characteristic. Therefore, the 
reviewer found that the requested services is 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 screening test have been met. Therefore, we decided that the Plan has to pre-
approve a colorectal cancer screening (G0121).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that the requested visits are medically necessary. The 
Plan denied your request. The Plan says service criteria is not met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for the enrollees condition beyond what was approved by the health plan. The enrollee has 
had prior therapy and the documentation does not reveal that the enrollee requires the ongoing unique skills of 
a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was 
approved. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollee's current condition or to prevent or slow further deterioration. There has been instruction in a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve fourteen (14) additional physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 23, 2022, to April 
15, 2022. 
 
You asked the Plan to pay for home health services. You say that a Notice of Admission (NOA) was submitted. 
The Plan denied your request. The Plan says the submitted NOA is for incorrect dates. 
 
The Plan must follow Medicare rules. Medicare rules say that or each admission to home health, the HHA 
notifies Medicare systems via submission of a Notice of Admission (NOA). A timely-filed NOA is submitted 
to and accepted within five calendar days after admission date. 
 
We looked at the file and Medicare rules. The submitted NOA shows an admission date of May 13, 2022, 
rather than the start of the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on March 23, 2022, to April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0042T provided on April 19, 2022. 
 
You asked the Plan to pay for procedure code 0042T. You say that these services were necessary and were 
ordered by a physician. The Plan denied your request. The Plan says this claim was billed with a diagnosis code 
which does not support the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are specific diagnosis codes which support 
the medical necessity of CPT code 0042T.  
 
We looked at the file and Medicare rules. Specifically, the diagnosis code billed on this claim is not included 
on the list of appropriate diagnosis codes to support the medical necessity of CPT code 0042T. Based on this 
information, we decided that Medicare rules for coverage of procedure code 0042T have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 0042T provided on April 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible, copayment, and coinsurance for a tendon 
injection, specialist office visit, and the triamcinolone acetonide drug provided on April 8, 2022. 
 
You asked the Plan to waive the deductible, copayment, and coinsurance for the injection, specialist office 
visit, and triamcinolone acetonide. You say that you have never paid this much for the service before. 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. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services.  The injection procedure falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the injection was received on April 8, 2022.  
 
Per the EOC, only the injection procedure is subject to the deductible. The allowed amount for this is $39.57. 
This amount is applied to your deductible. The specialist office visit is not subject to the deductible, and 
therefore the $35 copayment is applied. This item/service falls within the physician/practitioner services, 
including doctor's office visits (specialist) benefit category. The triamcinolone acetonide drug is also not 
subject to the deductible, and the 20% coinsurance is applied (4.56 allowed amount x 20% = $0.91). This 
item/service falls within the Medicare Part B prescription drugs benefit category. The total for all services is 
$75.48. 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 deductible, copayment, and coinsurance for a tendon injection, 
specialist office visit, and the triamcinolone acetonide drug provided on April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Free Style test strips and monitor. 
 
You asked the Plan to pre-approve Free Style test strips and monitor. You say that you disagree with the denial. 
The Plan denied your request. The Plan says you do not use an insulin pump and there is no significant visual 
impairment that would prevent you from using the preferred brands, you do not meet criteria of medical 
necessity for an exception. 
 
The Plan must follow Medicare rules. Medicare rules say that test strips and monitors must be obtained from a 
preferred vendor. 
 We looked at the file and Medicare rules. The EOC confirms you must receive your test strips and monitors 
from a preferred vendor. The EOC also confirms Freestyle test strips and monitors are not a preferred vendor 
and are not covered. The file does not include any documentation from your physician documenting why you 
require this specific brand of test strips. Based on this information, we decided that Medicare rules for coverage 
of Free Style test strips and monitor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Free Style test strips and monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on May 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing 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 the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on May 9, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the requested drug no longer requires prior 
authorization. You also say that the enrollee has osteoarthritis. The Plan denied your request. The Plan says the 
enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drug. The reviewer found there is no documentation to indicate 
that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this is supported in the documentation. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 6, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were told you 
were completely paid, but then you received this bill. You also say that you do not have any money to pay this 
bill. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the 
problem focused limited oral evaluation (D0140) provided on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3?R MIS fusion plate. 
 
You asked the Plan to pre-approve a Minuteman G3?R MIS fusion plate. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a Minuteman G3?R MIS fusion plate. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Minuteman procedure is experimental. 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 a Minuteman G3?R MIS fusion plate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Minuteman G3?R MIS fusion plate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 4, 2022.