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

 
We decided that the Plan does not have to pay for the gene panel testing provided on July 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that the gene panel will guide appropriate medical 
management of the enrollee. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 
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 gene panel was billed with multiple codes. If a single procedure is performed, only one 
HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on July 12, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the specimen collection provided on December 30, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that this code 
is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code C9803 is hospital outpatient clinic visit specimen 
collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), 
any specimen source. 
 
We find that CPT code C9803 has a status indicator of Q1. The claim has a bill type of 131, which indicates a 
hospital outpatient. Procedures with a status indicator of Q1 may be paid separately when there are no other 
specified services on the same day or claim. Based on this information, we decided that Medicare rules for 
coverage have been met. Therefore, we decided that the Plan has to pay for the specimen collection provided 
on December 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on August 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are the professional component of this 
claim. The Plan denied your request. The Plan says the claim is lacking information needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The claim in this case did not include the rendering provider or their provider number. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on August 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring of interstitial 
tissue fluid via a subcutaneous sensor for a minimum of 72 hours provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ambulatory continuous glucose monitoring. You say that this service was 
medically necessary. The Plan denied your request. The Plan says this service is not covered because it was 
provided OON without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring of 
interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours provided on March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110) and manual 
therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more 
regions, each 15 minutes (97140) provided from February 1, 2022, to February 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the physical therapy services. You say that the services were provided in good 
faith, and you expect payment. The Plan denied your request. The Plan says these services are not covered 
because they were provided OON without prior authorization. The Plan also says that the referring provider is 
OON as well. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110) 
and manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 
1 or more regions, each 15 minutes (97140) provided from February 1, 2022, to February 23, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) and cone beam computed tomography (CT) 
capture and interpretation with limited field of view  less than one whole jaw (D0364) provided February 18, 
2022. 
 
You asked the Plan to pay for the dental consultation and cone beam CT scan. You say that these services were 
necessary to evaluate your dental issues. The Plan denied your request. The Plan says these services are not 
covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) and cone beam computed tomography (CT) capture and interpretation with limited field of view  less 
than one whole jaw (D0364) provided February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic testing supplies provided on November 22, 2021, to 
February 19, 2022. 
 
You asked the Plan to pay for diabetic testing supplies. You say that the items at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
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 and when the information in the patients medical record adequately 
supports the medical necessity for the item. 
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 
diabetic testing supplies provided on November 22, 2021, to February 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 16, 
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 there would need to be an allowed modifier on this claim. 
 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 imaging services provided to the enrollee on January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anesthesia provided on January 5, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Anesthesia. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Anesthesia provided on January 5, 2022 by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81238, 81226, 81225, 81335, 
81230, 81241, 81291, and 81240 provided on October 6, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81238, 81226, 81225, 81335, 81230, 81241, 81291, and 81240 are not supported in the 
medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage 
of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing coded 81238, 81226, 81225, 81335, 81230, 81241, 81291, and 81240 provided on October 6, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found recent post-operative notes describe the enrollee as hemodynamically stable and neurologically stable and would not be expected to require a higher level of care from the receiving 
hospital that would likely cross 2 midnights. There was insufficient medical justification for transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
January 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this appeal should be approved and paid at 
the established rate of $901.82 for the Genesight single-gene testing under CPT code 81479. The Plan denied 
your request. The Plan says the records do not support medical necessity for the service. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records document that the enrollee presented to the medical provider on 
01/10/2022 requesting the PGx testing, and no documentation was provided in the office visit note that clinical 
factors were being considered at that time with regard to which medication would be most appropriate to treat 
the enrollee. As stated in the Local Coverage Determination (LCD) MolDX: Pharmacogenomics Testing 
(L38394): "The selection of the medications in question must be derived from clinical factors/necessity rather 
than from a PGx test." 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure (81479) provided January 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for esophagogastroduodenoscopy (43239, 43251) provided to the enrollee 
on September 23, 2021. 
 
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 that the records do not support the services 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 
the denied codes is: 
 
CPT 43239: 
 
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple 
 
CPT 43251: 
 
Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by 
snare technique 
 
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 both of the billing codes in dispute are 
appropriate for the procedure rendered on 9/23/21. The provided record supports that he underwent a 
diagnostic EGD, at which time a polypoid tumor was removed by snare technique from the stomach. 
 
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 
esophagogastroduodenoscopy (43239, 43251) provided to the enrollee on September 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on 
December 16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services provided to the enrollee on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee received services that were deemed 
medically necessary at the time of treatment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on November 17, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided by an out-of-network 
provider on September 23, 2020. 
 
You asked the Plan to pay for an extraction. You say that the Plan should pay for this. The Plan denied your 
request. The Plan says the rendered dental 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 pay for an 
extraction (D7140) provided by an out-of-network provider on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection. 
 
You asked the Plan to pre-approve an epidural injection. You say that an epidural injection is medically 
necessary. The Plan denied your request. The Plan says an epidural injection does not meet the Medicare 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural injection. Our reviewer says 
that an epidural injection is not medically necessary. Our physician reviewer found that according to the 
Medicare coverage criteria, if a prior epidural injection procedure provided limited or no relief, a second 
epidural injection utilizing the same method, technique or medication to the same level will be considered not 
medically reasonable and necessary. In addition, for caudal or interlaminar injections, only one level may be 
performed, and not in conjunction with transforaminal injection in the same region. Caudal or interlaminar 
injection is not considered medically reasonable and necessary in conjunction with transforaminal injections at 
the same session, for the same level, or within three contiguous levels of the same region (lumbosacral or 
cervicothoracic). In this case, there is no documentation of 50% pain relief for at least 3 months. It has also 
been noted that caudal ESI's and TFESI's have been performed during the same session, which is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ZIP procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is limited data on long-term safety and efficacy available available in the 
current medical literature. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested ZIP procedure, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the ZIP procedure for the enrollee.