Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 28, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that this provider was the only one available to do a 
telehealth visit as the enrolle was homebound. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth visit 
provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there was no documentation of unstable medical 
conditions that could not be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the claim does show that the required unique identifier was reported. 
Therefore, we decided that the Plan has to pay for the laboratory services provided on September 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo System (0266T). 
 
You asked the Plan to pre-approve a Barostim Neo System. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is considered experimental. 
 
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 a Barostim Neo System. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. 
 
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 Barostim Neo System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo System (0266T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 3, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 81334, 81345, 81272, and 
81218. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
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 
October 3, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81314, 
81334, 81345, 81272, and 81218.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1206) provided on November 3, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, fluoride application is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of 
fluoride (D1206) provided on November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
18, 2022.  

You asked the Plan to pay for procedure code 97010. You say that this claim was denied for no authorization, 
but you do have an authorization on file for this date of service. The Plan denied your request. The Plan says 
procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 provided on October 26, 2022. 
 
You asked the Plan to pay for procedure code A0425. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for procedure code A0425 is 250. You billed 268 units of this code, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code A0425 provided on 
October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96361, 96365, and 96366 billed for date of 
service October 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges are appropriate for the level of 
services provided. The Plan denied your request. The Plan says the codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes 96361, 96365, and 96366 have a PC/TC indicator of 5. The claim shows that the place 
of service was 23, a hospital emergency room. Payment may not be made for these services when they are 
provided to patients in a hospital outpatient department. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 96361, 96365, and 96366 billed for date of service October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid panel (84439, 84443, 84480) provided on January 
20, 2022. 
 
You asked the Plan to pay for the thyroid panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim was submitted with 
only one diagnosis code which indicates that this test was provided as a screening. The records provided do not 
include sufficient documentation from the referring provider to support that this panel was medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also 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. 
 
The test at issue in this appeal, the thyroid panel, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. In addition, no medical records or progress notes from the 
referring provider were submitted to support the medical necessity of this test. Therefore, we decided that the 
Plan does not have to pay for the thyroid panel (84439, 84443, 84480) provided on January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery. 
 
You asked the Plan to pre-approve cataract surgery. You say that  The Plan denied your request. The Plan says 
the notes do not show that the enrollee has cataracts that are affecting their activities of daily living. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 cataract surgery have been met. 
Specifically, the medical records provided were very limited and do not meet the documentation requirements 
for coverage of cataract surgery. Therefore, we decided that the Plan does not have to pre-approve cataract 
surgery.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit with the requested tertiary level of care provider.

You asked the Plan to pre-approve an office visit with the requested tertiary level of care provider. You say that the requested office visit with a tertiary level of care provider is medically necessary. The Plan denied your request. The Plan says that the member does not meet tertiary level of care guidelines.

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 an office visit with the requested tertiary level of care provider. Our reviewer says that the office visit with the requested tertiary level of care provider is considered medically reasonable and necessary in this case. Our physician reviewer found given your lengthy hospitalization in the past and the number of physician's you have seen for this condition, it makes sense to see the endocrinologist that your surgeon has indicated is best for you given your likely need for adrenal surgery. This will facilitate the best level of care and coordination of care from many perspectives.

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 office visit with the requested tertiary level of care provider have been met. Therefore, we decided that the Plan has to pre-approve an office visit with the requested tertiary level of care provider.

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 issue reimbursement for the extraspinal chiropractic manipulative 
treatments (98943) provided from August 9, 2022, through October 18, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
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 issue reimbursement for the extraspinal chiropractic manipulative treatments 
(98943) provided from August 9, 2022, through October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental in cases of spinal surgery. More research is 
needed to show safety and efficacy when used as bone graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics panel testing provided on October 11, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes are bundled into other claim lines. 
 
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 code 81401 from line 25 of the claim at issue, and code 81479 from claim line 26 were 
denied as bundled services. The claim information shows that the codes at issue were billed multiple times, 
indicated on lines 45 and 46 for code 81401, and lines 47 and 48 for code 81479. Codes should not be 
unbundled for a single service.  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 pharmacogenetics panel testing provided 
on October 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional units/hours of neuropsychological testing 
evaluation services (96133). 
 
You asked the Plan to pre-approve additional hours of neuropsychological testing evaluation. You say that the 
additional time for this service is medically necessary. The Plan denied your request. The Plan says the 
additional units requested are 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 pre-approve additional hours of neuropsychological 
testing evaluation. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee is being evaluated for a cognitive 
deficit. The enrollees plan has already authorized some neuropsychological services for the member. A request has been made for coverage of additional time. However, the records provided for review did not clearly 
demonstrate why additional units/time are necessary for the evaluation of this enrollees condition. There was 
no indication of any specific testing that was going to be performed (beyond that which had been approved) 
that would require authorization of extra time. Such a request would otherwise essentially exceed the enrollees 
clinical needs at this time and would not reflect the most appropriate level of care that could be provided. In as 
much, medical necessity cannot be established at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional hours of neuropsychological testing evaluation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve two additional units/hours of 
neuropsychological testing evaluation services (96133).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381), drugs or medicaments dispensed in 
the office for home use (D9630), and gingival irrigation-per quadrant (D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you have gum disease, and this is risking 
your health by causing infection. The Plan denied your request. The Plan says the services requested are non-
covered codes and not eligible for coverage under the medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381) and drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798, 87481 and 87801) provided on 
November 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these services were a panel which 
should only be billed with one code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan does not cite the rule used to make this denial. We are 
unable to find this rule in a determination which applies to the state where these services were provided. 
Without a clear citation, the Plan's denial is not supported. Therefore, we decided that the Plan has to pay for 
laboratory services (87150, 87798, 87481 and 87801) provided on November 26, 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.