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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 76705. The Plan denied your request. The Plan says payment for 
code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a subcutaneous injection of filling material  
(e.g., collagen). 
 
You asked the Plan to pre-approve a subcutaneous injection of filling material (e.g., collagen). You say that a 
subcutaneous injection of filling material (e.g., collagen) is medically necessary. The Plan denied your request. 
The Plan says a subcutaneous injection of filling material (e.g., collagen) is 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 a subcutaneous injection of filling 
material (e.g., collagen). Our reviewer says that a subcutaneous injection of filling material (e.g., collagen) is 
not considered medically reasonable and necessary in this case. Our physician reviewer found that it is well 
established that you are suffering with painful metatarsalgia bilaterally, especially noted sub fifth metatarsal 
heads. The records stated that walking is difficult, and you have failed to achieve pain relief with padding. 
Medicare guidelines advise that Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. The treatment must be safe and effective, not mainly for the convenience of the patient or the physician, not experimental or investigational, and appropriate in that the treatment is furnished in accordance 
with accepted standards of medical practice for the diagnosis or treatment of the patients condition. These 
treatments must also meet but not exceed the patients medical needs. Leneva is an allograft adipose matrix 
used to inject over areas of prominence for cushioning. Although this medication is FDA approved, it is 
certainly not standard of care for painful metatarsalgia. Furthermore, studies do show that the injection material 
may dissipate over time and not allow for pain relief.  Standard of care like this would be customized orthotics 
with offloading accommodations to defer friction and pressure from the areas of prominence. Therefore, the 
requested Leneva is not medically reasonable or necessary in that it would exceed your medical needs and 
certainly not be as beneficial as an existing and available medical treatment that is considered standard 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 a subcutaneous injection of filling material (e.g., collagen) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a subcutaneous injection of filling material 
(e.g., collagen).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the services rendered to the enrollee was 
medically necessary and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on February 22, 
2022, by an out-of-network (OON) provider.
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 admission is a medical necessity. You say that 
you fractured your hip about six weeks ago and was in a nursing home where you were able to walk but due to 
lack of therapy you are now in a wheelchair. The Plan denied your request. The Plan says based on Medicare 
guidelines, the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you 
have not shown that you require fifteen hours per week of rehabilitative services and regular physician 
evaluation. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) implant trial. 
 
You asked the Plan to pre-approve an SCS implant trial. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are 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 an SCS implant trial. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not had multiple medication trials, he has not had recent physical therapy or a surgical consultation. He does not have an 
evidence based indication for a SCS trial. The request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SCS implant trial have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (SCS) implant trial.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus tumor origin test (81479) billed for date of service 
November 19, 2021. 
 
You asked the Plan to pay for the tumor origin testing. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that this claim was billed with an incorrect date 
of service as the reported date must be the date the specimen was collected. 
 
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 rules also say that generally laboratory services should be reported with the date of the specimen 
collection as the date of service. However, there are three exceptions to this rule. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged nor discounted the exceptions to the 
rule applied in their decision to deny this claim. Based on the documentation provided, it appears that this 
sample collection was provided during a biopsy procedure, and it would have been inappropriate to collect this 
sample outside of this hospital procedure. It also appears that the results of this test were not necessary to 
influence the hospital care at the time of collection. This means that an exception to the rule has been met, and 
the correct date of service would be the date the test was performed. Therefore, we decided that the Plan has to 
pay for the Tempus tumor origin test (81479) billed for date of service November 19, 2021.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 25, 2022. 
 
You asked the Plan to pay for F1CDx. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5255) purchased on January 14, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid. You say that you were not informed that your hearing aid 
benefits had changed since 2021. You also say you are on a very limited budget, and feel this denial is unfair. 
The Plan denied your request. The Plan says this hearing aid was not purchased through the Plan's approved 
hearing vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by an approved hearing vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5255) purchased on January 14, 2022, from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found based on the provided documentation, the enrollee did not seem to suggest a need for a prolonged hospital visit as she was stable. There was no indication that the enrollee would require 
hospital care that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator (PNS). You say that the requested PNS is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested PNS. 
 
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 peripheral nerve stimulator (PNS). 
Our reviewer says that the enrollee does not meet criteria for the requested PNS.  Our physician reviewer found the enrollee has right cervical radiculopathy with right shoulder pain. She has 
tried steroid injections, Celebrex and Physical therapy. The request is for PNS for right shoulder pain. There is 
not enough published data to support the use of PNS in right shoulder pain or radiculopathy. The request is 
deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a peripheral nerve stimulator (PNS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a peripheral nerve stimulator (PNS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31536 billed for date of service February 2, 
2022. 
 
You asked the Plan to pay for procedure code 31536. The Plan denied your request. The Plan says payment for 
code 31536 is bundled into payment for code 31572.  
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 31536 
is a column II code to column I code 31572. 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 31536 billed for date of service February 2, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus xT Solid Tumor and Heme comprehensive testing panel 
(81455) billed for date of service April 11, 2022. 
 
You asked the Plan to pay for tumor testing. You say that this service was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that this claim was billed with an incorrect date 
of service as the reported date must be the date the specimen was collected. 
 
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 rules also say that generally laboratory services should be reported with the date of the specimen 
collection as the date of service. However, there are three exceptions to this rule. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged nor discounted the exceptions to the 
rule applied in their decision to deny this claim. Based on the documentation provided, it appears that this 
claim is for testing which was performed on a tumor specimen which was collected in a hospital setting. It 
appears that one of the exceptions to the applied rule have been met, and the correct date of service would be 
the date the test was performed. Therefore, we decided that the Plan has to pay for Tempus xT Solid Tumor 
and Heme comprehensive testing panel (81455) billed for date of service April 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary cancer testing of BRCA1 and BRCA2 genes 
(81162). You asked the Plan to pre-approve hereditary cancer testing. You say that this test is necessary as the enrollee 
has a family history of cancer. The Plan denied your request. The Plan says this test is not covered for 
beneficiaries who have no personal history of cancer. 
 
The Plan follows Medicare rules. The rules say that BRCA1 and BRCA2 genetic testing is considered 
medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with 
the BRCA mutation who meets certain other criteria. The rules also explicitly say that screening tests, with the 
exception of the few tests listed in the Medicare rules section, are not covered. 
 
The enrollee does not have a current diagnosis or a personal history of a cancer associated with the BRCA 
mutation. This means that the test at issue in this appeal, hereditary cancer testing, is being requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes, and this testing is only 
considered medically necessary for a patient with a current diagnosis or personal history of certain cancers. 
Therefore, we decided that the Plan does not have to pre-approve hereditary cancer testing of BRCA1 and 
BRCA2 genes (81162).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for telehealth visit provided on April 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Vertiflex device. 
 
You asked the Plan to pre-approve placement of a Vertiflex device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 placement of a Vertiflex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The 
Vertiflex device is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the 
requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a Vertiflex device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve placement of a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vestibuloplasty (D7340) and a frenulectomy (D7962) 
provided by a participating provider. 
 
You asked the Plan to pre-approve a vestibuloplasty and a frenulectomy. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
vestibuloplasty (D7340) and a frenulectomy (D7962) provided by a participating provider.