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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2022, by an 
out-of-network provider. 
 You asked the Plan to pay for procedure code 81345. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. The Plan states 
this provider is out-of-network, the services were not referred by a network provider, and the services were not 
urgent or emergent, nor were they approved in advance. 
 
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 care that cannot be provided by network providers. 
 
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 81345 
is a column II code to column I code 0089U. 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 the laboratory services provided on September 1, 2022, by an 
out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for 
treatment of your health problem. 
 
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 the Vertiflex device is experimental. More research is needed. We 
looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GeneSight gene panel. 
 
You asked the Plan to pre-approve GeneSight gene panel. 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 there is a limited coverage policy for 
pharmacogenomics testing (PGx) including single gene, multi-gene panels, and combinatorial tests. These tests 
are generally covered (with a few exceptions) as described in further detail below to improve safety in the use 
of specific medications by avoiding potentially harmful medications,doses and/or adverse reactions known to 
occur with certain genotypes. 
 
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 GeneSight gene panel. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the GeneSight gene panel testing at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee as detailed in the LCD. Provided 
medical records do not document that the test is being ordered to improve safety in the use of specific 
medications by avoiding potentially harmful medications, doses and/or adverse reactions known to occur with 
certain genotypes, as required by the LCD. The only records provided are a medical necessity/order form 
generated by the test vendor and signed by the medical provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight gene panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve GeneSight gene panel.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code(s) 88104, 88305, 88312, and 88361 billed for date of 
service April 12, 2022. 
 
You asked the Plan to pay for procedure code(s) 88104, 88305, 88312, and 88361. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components are payable under the physician fee schedule when furnished in institutional settings 
where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC). 
 
The records indicate that this service was provided to the enrollee at an ASC. This means that both the 
professional and technical component for the CPT code(s) are payable to the independent laboratory. A 
modifier is not required. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88104, 88305, 88312, and 88361 have been met. Therefore, we decided that the Plan has to pay for 
procedure code(s) 88104, 88305, 88312, and 88361 billed for date of service April 12, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
codes are mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  If the side is not identified in the 
medical record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. The services in question were billed with left-sided and right-sided 
diagnosis codes. However, since a bilateral diagnosis code exists, it should be used in this case. 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 the services provided on May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get stronger before you can return home. 
The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
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 that you do not require intensive rehabilitation services or frequent physiatry 
oversight to address functional loss due to chronic spinal stenosis.  
 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 the IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 23, 2022, 
to March 24, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 23, 2022. The NOA was not received by the Plan until August 27, 
2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 23, 2022, to March 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 14, 2022, to 
January 25, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009). 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
Q codes. 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 
January 14, 2022, to January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 24, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 4, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the non-
participating provider is responsible to verify coverage and obtain prior authorization before rendering 
services. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 28, 2022 to 
February 23, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA claim was not submitted with a valid type of bill. All NOA claims must be submitted 
with type of bill 032A. Therefore, we decided that the Plan does not have to pay for home health services 
provided on January 28, 2022 to February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on December 20, 2021. 
 You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation does not support that the enrollee 
met criteria for the items rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the supply 
allowance for therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay 
for the supply allowance for therapeutic continuous glucose monitor (CGM) provided on December 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 63090 & 63091 billed for date of service 
April 19, 2021. 
 
You asked the Plan to pay for procedure codes 63090 & 63091. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 63090 is bundled into payment for 
code 22224. Code 63091 is an add-on code. 
 
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 63090 
is a column II code to column I code 22224. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 63091 is an add-on code billed without a primary procedure. 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 codes 63090 & 63091 billed for date of service April 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for radiological procedures (code 01916) provided on 
July 6, 2021. 
 
You asked the Plan to pay for anesthesia for radiological procedures. The Plan denied your  
request. The Plan says that the service is not covered based on the Medicare LCD. 
 
The Plan must follow Medicare rules. Medicare rules say that code 01916 is covered when billed with 
diagnosis code E11.51. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of anesthesia for radiological procedures have been met. Therefore, we decided that the Plan has to 
pay for anesthesia for radiological procedures (code 01916) provided on July 6, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 8, 2021 and  
April 15, 2022 by an out-of-network provider. 
 
You asked the Plan to pay for psychotherapy. You say that you received a retroactive referral to see this 
provider starting on November 1, 2021 through September 29, 222 with the authorization numbers 158744632 
and 158761590. The Plan denied your request. 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 
Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. Additionally, the Plan says that the Plan made an outbound call to the members PCP to 
determine if the PCP had referred the member to the treating provider. The representative from the PCP's office 
stated there is no referral for these dates of services. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on December 8, 2021 and  
April 15, 2022 by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an unlisted procedure, posterior segment (procedure code 67299) 
provided to the enrollee on May 24, 2022. 
 
You asked the Plan to pay for the services. You say that properly focusing the proton beam required that 
tantalum rings be placed on the eye. The Plan denied your request. The Plan says that scleral application of 
tantalum rings is not a covered benefit. 
 
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 67299 is "Unlisted procedure, posterior segment." 
 
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 supported by the medical records. Our reviewer found that the medical records support the use of 
CPT 672329 to represent an unlisted procedure of properly focusing the proton beam. This required that 
tantalum rings be placed on the eye. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
an unlisted procedure, posterior segment (procedure code 67299) provided to the enrollee on May 24, 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 pay for lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on June 26, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee had two trips on this date. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 10, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on 
June 26, 2022.