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

 
We decided that the Plan does not have to pay for the respiratory pathogen panel (87486, 87496, 87498, 84502, 
87532, 87541, 87581, 87634, 87640 and 87798) provided on August 11, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that this test was medically necessary 
and was ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this panel 
was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel (87486, 87496, 
87498, 84502, 87532, 87541, 87581, 87634, 87640 and 87798) provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transplant listing for a kidney. 
 
You asked the Plan to pre-approve a transplant listing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says that the records sent in, do not show that you had 
a dental clearance from your dentist in the last twelve months. The records also do not show results that you 
had a normal colonoscopy. This information is needed to show you are ready to be listed for a kidney 
transplant. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pre-approve a transplant listing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have been cleared as a suitable transplant recipient by a nationally recognized center of 
excellence and have been rejected by your insurance company. You have been deemed a candidate for 
transplantation by the kidney transplant center who have taken in account your medical history and there is no 
reason to go against the center's expert opinion. You are suitable for transplant. The decision for transplant 
candidacy is typically a decision deferred to the transplant center. The reasons for rejecting the transplant were 
not reasonable, therefore, our reviewer will concur the opinion of the transplant center. 
 
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 transplant listing have been met. Therefore, we decided that the Plan has to 
pre-approve a transplant listing for a kidney.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9090 and A9270 billed for date of service 
November 17, 2021 to February 28, 2022. 
 
You asked the Plan to pay for procedure codes S9090 and A9270. You say that this should be paid for. 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 S9090 has a Status Indicator of I on the Physician Fee Schedule. Additionally, 
A9270 was billed. The definition of this code is "non-covered item or service." This means that procedure code 
S9090 and A9270 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9090 and A9270 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes S9090 and A9270 billed for date of service November 17, 2021 to 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
May 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service is not supported without the required documentation. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 interval history is not detailed 
and does not address all of the diagnoses listed in the assessment. The documented medical decision making is 
not of high complexity. As such, the billing of CPT 99233 is not supported. 
 
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 subsequent hospital care (procedure code 99233) rendered on May 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. 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 Supartz. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Synvisc, Durolane, and Gelsyn-3 would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 Tissue Next testing (81479) provided on December 4, 
2021. 
 
You asked the Plan to pay for Guardant360 Tissue Next testing. You say that this test was medically necessary, 
is covered by Medicare and was reported correctly. The Plan denied your request. The Plan says that the claim 
for this molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. The rules also 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, review of the claim shows that the required unique identifier was 
reported. The Plan has provided no other reason for denial in this case. Therefore, we decided that the Plan has 
to pay for Guardant360 Tissue Next testing (81479) provided on December 4, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 14, 2022, to 
May 13, 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 there is no valid certification. 
 
The Plan must follow Medicare rules. The rules say that allowed practitioners in addition to physicians, can 
certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care 
plan. 
 
We looked at the file and Medicare rules. The file shows that there is no valid certification order for the 
services. 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 home health services rendered from 
April 14, 2022, to May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the routine eye wear (V2203, V2750, 
V2799) and medical eye exam (99214) provided on November 15, 2022. 
 
You asked the Plan to provide additional payment for the routine eye wear and medical eye exam. You say that 
the eye exam should be covered in full. The Plan denied your request. The Plan says the eye exam was billed 
with a medical diagnosis and was processed correct with a copayment. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. 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 $55 copayment for Medicare-covered exams. 
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. You have been 
asked to pay a $55 copayment for the medical eye exam. This item/service falls within the medical vision 
benefit category. This means that you have been asked to pay the correct amount for the eye exam based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The routine eyewear is not covered under your benefits. Therefore, we decided that the Plan does 
not have to provide additional payment for the routine eye wear (V2203, V2750, V2799) and medical eye exam 
(99214) provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 36000. The Plan denied your request. The Plan says procedure 
code 36000 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lyrica. 
 
You asked the Plan to pre-approve Lyrica. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Lyrica.  
 
Benefits for Lyrica may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation (E2300). 
 
You asked the Plan to pre-approve power seat elevation. You say that this is necessary for the enrollee. The 
Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation have not been met. Therefore, we decided that the Plan does not have to pre-
approve power seat elevation (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code E2300. 
 
You asked the Plan to pre-approve procedure code E2300. You say that the enrollee is not able to walk on their 
own. You say that the enrollee cannot get out of bed without a wheelchair. You also say that the supplier is not 
cooperating with you or the enrollee's plan to provide documentation to get this approved for the enrollee. The 
Plan denied your request. The Plan says the seat lift does not serve a medical purpose and cannot be covered.  

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 procedure code E2300.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service March 30, 2022. 
 
You asked the Plan to pay for code 99223. You say that this service was medically necessary and the records 
support payment. The Plan denied your request. The Plan says code 99223 is not supported in the medical 
record. The medical records do not support a comprehensive examination and medical decision making of high 
complexity. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; a 
comprehensive exam; and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the enrollee was a then, 74 year-old female with a history 
of dementia, diabetes mellitus, cerebrovascular accident, hypertension, anxiety/depression, and legal blindness who presented to the emergency room from a Memory Disorder facility with bloody stools. She was evaluated 
with a history and physical exam, laboratory studies and a computed tomography scan of the abdomen/pelvis. 
She was started on IV antibiotics and admitted with presumed diverticulitis. The review indicates that 
procedure code 99223 was not supported in the medical records. The enrollee underwent a comprehensive 
history but no comprehensive exam or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20700 billed for November 18, 2021. 
 
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 code 20700 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20700 is manual preparation and insertion of drug-
delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure). 
 
We find that CPT code 20700 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 procedure code 20700 billed for November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20553 billed for August 22, 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 code 20553 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20553 is injection(s); single or multiple trigger point(s), 3 
or more muscles. 
 
We find that CPT code 20553 is not supported in the medical record. Specifically, there is no documentation of 
an injection of a single or multiple trigger point for three or more muscles.. 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 procedure code 20553 billed for August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray study of swallowing function with contrast material 
(74230) and single contrast x-ray of upper digestive tract (74240) provided on November 10, 2022. 
 
You asked the Plan to pay for the x-ray study of swallowing function with contrast material and single contrast 
x-ray of upper digestive tract. The Plan denied your request. The Plan says these services are excluded from 
coverage when performed in a mobile setting. 
 
The Plan must follow Medicare rules. Medicare rules say that barium swallow studies will not be covered when 
performed in a mobile setting.  
 
We looked at the file and Medicare rules. The record shows that the barium studies were performed in a mobile 
setting at the nursing home where the enrollee is residing. Based on this information, we decided that Medicare 
rules for coverage of the x-ray study of swallowing function with contrast material and single contrast x-ray of 
upper digestive tract have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray 
study of swallowing function with contrast material (74230) and single contrast x-ray of upper digestive tract 
(74240) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240). 
 
You asked the Plan to pre-approve a pontic. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says the requested service 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 pre-approve a 
pontic (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor supplies billed with code 
K0553 for September 14, 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 the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies 
billed with code K0553 for September 14, 2022.