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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81291, 81355, 0031U, 0032U, 0033U, 81479, 81407, 81406, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that these lab services were medically 
necessary and ordered by the patient's physician. You also claimed that you billed with the correct Place of 
Service. The Plan denied your request for two reasons. The Plan says panel testing should be billed using one 
CPT code on the claim. The Plan also claims that you billed with an incorrect Place of Service on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. Medicare rules also 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. This was an NGS panel that was not billed with a single panel code 
as required. In addition, this claim was billed with the laboratory POS code. The records do not support that the 
sample was taken in a laboratory setting. In fact, the medical records explicitly state that the specimen was 
provided by the patient and sent directly to your lab on June 2, 2022, via a buccal swab.  In other words, the 
patient was not physically present in your lab at the time of specimen collection.  As a result, Place of Service 
81 is not appropriate in this case. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on June 2, 2022, billed with codes 81227, 81230, 81231, 81232, 81291, 81355, 0031U, 
0032U, 0033U, 81479, 81407, 81406, and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service August 26, 
2022. 
 
You asked the Plan to pay for procedure code 11720. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 11720 is bundled into payment for code 11719.  
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on August 
30, 2022. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this service was denied incorrectly. 
The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of GeneSight Psychotropic testing have been met. Therefore, we decided that the 
Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan did not submit any supporting medical records or documented attempts 
to obtain supporting records. Without supporting medical records, we cannot determine whether the enrollee 
meets criteria for a CGM. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor 
(CGM).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 12, 2021 to April 27, 
2021 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the home health services have been 
met. No clinical records were provided. The plan made multiple requests for medical records. None were 
provided. Therefore, we decided that the Plan does not have to pay for home health services provided on April 
12, 2021 to April 27, 2021
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99292 billed for date of service February 18, 2022. 
 
You asked the Plan to pay for procedure code 99292. You say that this service was reported correctly, and 
procedure code 99291 was reported on a separate claim which has already been paid. The Plan denied your 
request. The Plan says that they were unable to make a decision on this case within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan states in the provided narrative that critical care services 
have been paid; however, no documentation was provided to support that the previous denial of code 99292 
was overturned and paid. The Plan also did not provide any information to support that primary procedure code 
99291 had not also been billed in a separate claim for the enrollee on this date of service. Therefore, we 
decided that the Plan has to pay for procedure code 99292 billed for date of service February 18, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on September 29, 2022. 
 
You asked the Plan to pay for outpatient services. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says the type of bill submitted for this claim is not 
compatible with the primary taxonomy of the billing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rule 
say that hospital outpatient services should be reported on a 13x type of bill (TOB), while critical access 
hospital outpatient services should be reported on an 85x TOB. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, the record shows that the billing facility is a critical access hospital; however, this claim was submitted on a 131 TOB. Therefore, we decided that the Plan 
does not have to pay for outpatient services provided on September 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug. There is no indication that the 
plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) delivery and setup 
(A9901), provided on April 4, 2022. 
 
You asked the Plan to pay for the DME delivery and setup. You say that the service should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that delivery and service are an integral part of 
oxygen and durable medical equipment (DME) suppliers' costs of doing business. Such costs are ordinarily 
assumed to have been taken into account by suppliers (along with all other overhead expenses) in setting the 
prices they charge for covered items and services. As such, these costs have already been accounted for in the 
calculation of the fee schedules. Also, most beneficiaries reside in the normal area of business activity of one or 
more DME supplier(s) and have reasonable access to them. Therefore, Medicare  may not allow separate 
delivery and service charges for oxygen or DME except as specifically indicated or in rare and unusual 
circumstances when the delivery is not typical of the particular supplier's operation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME delivery and setup have not been met. Specifically, there is no documentation of rare or 
unusual circumstances that would allow for payment of delivery and service charges. Therefore, we decided 
that the Plan does not have to pay for the durable medical equipment (DME) delivery and setup (A9901), 
provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99080 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 99080. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99080 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 99080 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99080 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99080 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99080 billed for date of service September 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for ambulance services (A0433, A045) 
provided on November 26, 2021. 
 
You asked the Plan to provide reimbursement for ambulance services. You say that you would like to be 
reimbursed for these necessary services. The Plan denied your request. The Plan says the place of service 
submitted on this form is incorrect, and there is not sufficient proof of payment for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ambulance services have been met. 
Specifically, the documentation provided does not include adequate proof of payment. Although it is noted on 
the document that a transaction took place, there is no record or documentation of any specific payment type 
and it is not clear who paid for these services. Therefore, we decided that the Plan does not have to provide 
reimbursement for ambulance services (A0433, A045) provided on November 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  a subsequent nursing facility visit provided on October 25, 2022. 
 
You asked the Plan to pay for  a subsequent nursing facility visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that the services can be obtained from an in-
network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage (EOC). Without the 
EOC we are unable to determine if the claim was processed correctly based on the Plan benefits. Therefore, we 
decided that the Plan has to pay for a subsequent nursing facility visit provided on October 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244) and a tub stool or bench 
(E0245). 
 
You asked the Plan to pre-approve a raised toilet seat and a tub stool or bench. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
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 a raised toilet seat (E0244) and a tub stool or bench 
(E0245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device leads provided on August 17, 2022. 
 
You asked the Plan to pay for the TENS device leads. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the items rendered is not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted. In addition, the proof of delivery is not itemized to indicate the specific supplies. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device 
leads provided on August 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 99601. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service June 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for the services. You say that this service was reported correctly. The Plan denied 
your request. The Plan says the code used to report this service is not supported in the medical record. 
 
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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 describes 
EEG during non-intracranial monitoring for a spinal procedure, which was reimbursed. EEG recording in coma 
or sleep would not be reported with the procedures reported. Any additional EEG would be included in the 
primary neuromonitoring procedure.  
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 code 95822 billed for date of service May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73702 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 73702. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73702 is bundled into payment for code 
75635. 
 
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 73702 
is a column II code to column I code 75635. 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 73702 billed for date of service October 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dental services on July 19, 2022, to 
September 14, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for the dental services.  
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the dental 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the dental services on July 
19, 2022, to September 14, 2022.