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

 
We decided that the Plan does not have to pay for procedure code 88360 provided on February 24, 2022. You asked the Plan to pay for procedure code 88360. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this service was not billed in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT code 88360 is a physician pathology service which has both a professional component (PC) 
and technical component. This service was not billed with modifier 26 to indicate that only the professional 
component payment is requested. This means that payment is requested for both the PC and TC of this service. 
However, this service was provided to an enrollee who was in an inpatient hospital setting at the time the 
sample was collected, which means that the TC component is bundled into the facility payment. The TC 
portion of this service is not separately payable, and therefore this service is not supported as billed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 88360 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88360 provided on February 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 64447) provided to the 
enrollee on April 6, 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 denied codes cannot be verified. 
 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 64447: 
 
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve 
 
CPT 99100: 
 
Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to 
code for primary anesthesia procedure) 
 
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 in terms of CPT 64447, there is 
no separate consultation note from the surgeon asking for a separate post pain block.  The block note and 
ultrasound documentation is not submitted for review. Without this documentation, the request is not coded 
separately. 
 
Additionally, we find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. 
This means that this procedure is not separately payable. 
 
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 anesthesia services (procedure code 64447) provided to the enrollee on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal Infection Panel with Bacterial Add-On testing 
provided on March 8, 2022. 
 
You asked the Plan to pay for the Fungal Infection Panel with Bacterial Add-On testing. You say that the 
Fungal Infection Panel with Bacterial Add-On testing provided on March 8, 2022, was medically necessary. 
The Plan denied your request. The Plan says the Fungal Infection Panel with Bacterial Add-On testing provided 
on March 8, 2022, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Fungal Infection Panel with Bacterial 
Add-On testing. Our reviewer says that the Fungal Infection Panel with Bacterial Add-On testing provided on 
March 8, 2022, was not medically necessary. Our physician reviewer found it is well established in the medical documentation that this enrollee is suffering with a thick, painful, dystrophic, discolored, left hallux toenail. 
Standard of care for evaluation of toenails includes potassium hydroxide (KOH) and fungal culture. Bacterial 
cultures of a nail specimen can also be taken. In this particular case the medical documentation does not 
support that this enrollee has undergone KOH, fungal culture, or bacterial culture of the affected left hallux 
toenail. It appears that a Polymerase Chain Reaction (PCR) test exceeds the enrollees medical needs and is 
currently not accepted standard of care for evaluation of fungus or bacteria in a toenail. Therefore, the fungal 
infection panel with bacterial add-on testing provided on March 8, 2022, was 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 Fungal Infection Panel with Bacterial Add-On testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Fungal Infection Panel with Bacterial Add-On 
testing provided on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88361, 88312, 88305 and 88104 billed for 
date of service September 27, 2021. 
 
You asked the Plan to pay for procedure codes 88361, 88312, 88305 and 88104. You say that these services 
were necessary and should be paid. The Plan denied your request. The Plan says these services were not billed 
in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88361, 88312, 88305 and 88104 are services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88361, 88312, 88305 and 88104 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 88361, 88312, 88305 and 88104 billed for date of service September 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9500, S9501, and S9502 billed for date of 
service December 23, 2021 to December 29, 2021. 
 
You asked the Plan to pay for procedure codes S9500, S9501, and S9502. You say that these are valid codes. 
The Plan denied your request. The Plan says the billed codes are 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 codes S9500, S9501, and S9502 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes S9500, S9501, and S9502 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes S9500, S9501, and 
S9502 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S9500, 
S9501, and S9502 billed for date of service December 23, 2021 to December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided from July 6, 
2022, to July 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that you were not aware that 
outside of the previous state you resided in, your policy did not cover the cancer center or laboratory services 
without a prior authorization. The Plan denied your request. The Plan says a prior authorization was not on file. 
 
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 and laboratory services provided 
from July 6, 2022, to July 8, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
March 10, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
data element, admission/start of care date on the subsequent period of care claim does not match the admission 
date reported on the first period of care NOA claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from February 9, 2022, to March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an upper endoscopy on July 25, 2022. 
 
You asked the Plan to waive the copayment for an upper endoscopy. You say that you would like to appeal the 
cost share. 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 $100 
copayment for an upper endoscopy.  
 
You have been asked to pay a $100 copayment for an upper endoscopy. This item/service falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 copayment for an upper endoscopy on July 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on June 3, 
2022. 
 
You asked the Plan to pay for GeneSight Psychotropic testing. You say that this test was medically necessary 
and reasonable. The Plan denied your request. The Plan says the criteria for pharmacogenomic testing are not 
met in this case as there is insufficient documentation in the record, and the specific test provided is not 
covered by Medicare. 
 
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 GeneSight Psychotropic testing have 
been met. Specifically, no medical records or progress notes were received which show that the referring 
provider had the intention for this test to be performed. In addition, none of the documentation required by the 
LCD has been provided for review. Therefore, we decided that the Plan does not have to pay for GeneSight 
Psychotropic testing (81479) provided on June 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed at 
least two of the Plan's required drugs, Neulasta, Fulphila, or Udenyca. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Ziextenzo is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ziextenzo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019). 
 
You asked the Plan to pre-approve the personal care services. You say that you are appealing the denial of this 
service because you need help with your personal care. The Plan denied your request. The Plan says the 
requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care services, per 15 minutes (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services on June 16, 2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you would like to appeal the 
cost share. 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 $30 
copayment for urgent care services.  
 
You have been asked to pay a $30 copayment for urgent care services. This item/service falls within the 
urgently needed 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 copayment for urgent care 
services on June 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pay for the admission. You say that you would benefit from skilled nursing services due 
to your medical complexity. The Plan denied your request. The Plan says you can receive the care you need in 
another setting, such as home, a long-term care facility, or other outpatient setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. You do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0402 billed for date of service February 3, 2022. 
 
You asked the Plan to pay for code G0402. You say that this patient is new to Medicare so this service should 
be covered. The Plan denied your request. The Plan says you did not bill this service with the appropriate 
modifier in order for payment to be made. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for E/M services billed on the same day 
as a minor surgical procedure to be paid, they must be billed with an appropriate modifier to indicate that the 
E/M service is separate and distinct from the procedure itself.  In this case, you billed three separate codes for 
the date of service in question: 69209, 99214-25, and G0402. Codes 69209 and 99214-25 have been paid.  Code G0402 has been denied because it is considered an E/M service billed on the same day as a minor 
surgical procedure (i.e., code 69209).  According to Medicare rules, in order to allow for separate payment, 
code G0402 would need to have a modifier appended to it to indicate that it is separate and distinct from the 
surgical procedure.  You did not bill this code with a modifier, which is why this code was denied 
appropriately. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0402 have not been met. Therefore, we decided that the Plan does not have to pay for code 
G0402 billed for date of service February 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Injection to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an Injection. You say that you would like the plan to approve OON 
coverage. The Plan denied your request. The Plan says the service can be received in-network. 
 
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 pre-approve 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an Injection to be provided 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 provided on February 13, 2022 billed with 
codes 81275, 81235, 81206, and 81210. 
 
You asked the Plan to pay for the genetic testing billed. 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 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. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. 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 
February 13, 2022 billed with codes 81275, 81235, 81206, and 81210.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assisted facility visit provided on August 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an assisted facility visit. You say that this should be covered. The Plan denied 
your request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 assisted facility visit provided on August 16, 
2022, by an out-of-network (OON) provider.