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

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81162, 81301, 81311) 
provided on October 5, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81162, 81301, 81311) provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac risk assessment genetic screening test 
(81479) provided on October 6, 2021. 
 
You asked the Plan to pre-approve the cardiac risk assessment genetic screening test. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this 
screening is not covered in absence of symptoms. 
 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 cardiac risk assessment genetic 
screening test. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is a 57-year-old woman with a history of 
chronic obstructive pulmonary disease, sleep apnea, and pulmonary embolism. The Comprehensive Cardio 
Panel includes testing of 117 genes. The clinical documentation does not support that the testing in this case 
met, but did not exceed, the enrollee's medical need, and was at least as beneficial as an existing and available 
medically appropriate alternative. The testing is not considered to be an accepted standard of medical practice 
for the diagnosis or treatment of the enrollee's 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 the cardiac risk assessment genetic screening test have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the cardiac risk assessment genetic screening test 
(81479) provided on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J8540) provided on December 2, 2021. 
 
You asked the Plan to pay for code J8540. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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 J8540 is Dexamethasone, oral, 0.25 mg. 
 
We find that procedure code J8540 is not supported in the medical record for multiple reasons. Specifically, 
this code has a status indicator of "E" which means that it is excluded from the Physician Fee Schedule by 
regulation. No payment may be made for these codes. Additionally, the Medically Unlikely Edits (MUE) for 
this code for practitioners is 0, which means it is not eligible for reimbursement. Based on this information, we 
decided that Medicare rules for coverage of code J8540 have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J8540) provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that the enrollee will be sedated for their 
procedure. You say that the enrollee is coming from out of town alone. You also say that the enrollee cannot 
leave along after sedation as they have an existing condition and may have issues. The Plan denied your 
request. The Plan says the inpatient hospital admission is not medically necessary. 
 
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 inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the provided documentation does not indicate there are other high risk factors in the 
enrollee's medical history that might warrant hospital admission following this ambulatory procedure. The 
reviewer also found there was no suggestion that the enrollee would require hospital services 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an acute inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation provided on January 19, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the services are covered benefits, but the 
enrollee has exceeded frequency limits set in the subscriber agreement. Per member's plan benefits, she can get 
a comprehensive oral evaluation once every three plan years. This service was paid for date of service January 
27, 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service isn't covered 
because this service was already provided within the past three plan years. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation provided on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx pen (J3590). 
 
You asked the Plan to pre-approve Consentyx. You say that the requested medication has been prescribed and 
used for over 1 year with improvement and maintenance of the enrollee's diagnosis. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Cosentyx pen (J3590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interbody biomechanical device(s) (eg, 
synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when 
performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (CPT code 
22853), arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other 
than for decompression); each additional interspace (CPT code 22585), and arthrodesis, anterior interbody 
technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (CPT 
code 22558). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your records show a request for surgery at more than one level of your spine. The Plan 
states additional spinal levels can only be approved if surgery at the main level of your spine is approved. The 
Plan states surgery at the main level of your spine has not been approved at this time. 
 
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 [state the medical finding(s) upon which the physician based his/her conclusion] 
 
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 insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral 
anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc 
space in conjunction with interbody arthrodesis, each interspace (CPT code 22853), arthrodesis, anterior 
interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each 
additional interspace (CPT code 22585), and arthrodesis, anterior interbody technique, including minimal 
discectomy to prepare interspace (other than for decompression); lumbar (CPT code 22558).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional visits. You say that you have had progress with reduction in 
pain, you wish for more physical therapy to be provided. The Plan denied your request. The Plan says clinical 
progress is not sufficient to justify further therapy. 
 
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 the additional 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 your condition beyond what was approved by the health plan. You have had prior 
therapy and the documentation does not reveal that you require the 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. 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 your current condition or to prevent or slow further deterioration. 
There has been instruction in an independent home program. Ongoing skilled therapy is not 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for supplies and materials (except spectacles), 
provided by the physician or other qualified health care professional over and above those usually included 
with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) (99070) 
provided on December 23, 2021. 
 
You asked the Plan to reimburse you for supplies and materials. You say that you have paid the claim and are 
requesting a refund for the items purchased. The Plan denied your request. The Plan says 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 without a prescription. The item at issue is classified as a self-help device. 
 
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 reimburse you for supplies and materials (except spectacles), provided 
by the physician or other qualified health care professional over and above those usually included with the 
office visit or other services rendered (list drugs, trays, supplies, or materials provided) (99070) provided on 
December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on January 3, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, 
possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. 
Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CxBladder testing provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer on February 14, 2022. 
 
You asked the Plan to pay for the labial veneer. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says The service is not covered under the members contract 
under any normal circumstances. Per the members 2022 Evidence of Coverage the plan has limited dental 
benefits and the service is excluded. 
 
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 labial 
veneer on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining cost of the complete denture (D5110) provided on 
January 3, 2022. 
 
You asked the Plan to pay the remaining cost of the denture. You say that the denture is not well made. The 
Plan denied your request. The Plan says the denture is a covered service and that they paid $1,000 for the 
service. The Plan says that you are responsible for the charge of $52, that exceeded the $1,000 allowance. 
 
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. The Plan covers the denture 
when the services are medically necessary and reasonable.  
 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 100% of 
charges that exceeds the $1,000 allowance paid by the Plan for complete dentures. 
 
You have been asked to pay $52 out-of-pocket for the denture. Dentures fall within the Dental Services - 
Supplemental 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 pay the remaining cost of the remaining cost of the 
complete denture (D5110) provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular risk analysis (81479) provided on 
October 4, 2021. 
 
You asked the Plan to pay for hereditary cardiovascular risk analysis. You say that this was medically 
necessary and billed correctly. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular 
risk analysis have not been met. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular risk analysis (81479) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation on February 9, 2022. 
 
You asked the Plan to pay for limited oral evaluation. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says The service is a covered benefit, but the enrollee has 
exceeded limits set in the subscriber agreement. 
 
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 exam isnt covered 
because this service was already provided for the year. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you submitted medical documentation 
for review of medical necessity. The Plan denied your request. The Plan says they did not receive information 
to verify the sensor is 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 pay for the lumbar-sacral orthosis. Our physician 
reviewer found there is inadequate documentation that the enrollee meets the requirements listed in the LCD: 
Spinal Orthoses: TLSO and LSO (L33790) for Medicare coverage for the requested lumbar-sacral orthosis. 
Provided records do not clearly document that the orthosis is being ordered to reduce pain by restricting 
mobility of the trunk or to facilitate healing following an injury to the spine or related soft tissues or to facilitate healing following a surgical procedure on the spine or related soft tissue or to otherwise support weak 
spinal muscles and/or a deformed spine. 
 
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 22, 2021, 
through September 28, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the diagnosis code for Other Gram-negative sepsis (A41.59) is not supported by the hospital record for this hospital encounter. The Plan states the removal of the diagnosis code and change in 
DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely on 
coding guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with Gram-negative sepsis (A41.59). We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for inpatient hospital care. Our physician reviewer found the 
review has determined that diagnosis code for Other Gram-negative sepsis (A41.59) was not supported in the 
records provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided from September 22, 2021, through September 28, 2021.