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

 
We decided that the Plan does not have to pay for the Genomic Testing Cooperative (GTC) hematology profile 
(81455) provided on September 8, 2022. 
 
You asked the Plan to pay for the GTC hematology profile. You say that this is a Medicare-covered test which 
was medically necessary for this enrollee. The Plan denied your request. The Plan says this test is not medically 
necessary, as the enrollee did not require broad genomic profiling for a hematological malignancy work-up. A 
large untargeted panel exceeds the enrollee's needs. 
 
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 GTC hematology profile. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found next generation sequencing (NGS) on peripheral blood is not considered a standard 
of care for the work-up of thrombocytopenia or monoclonal gammopathy of undetermined significance 
(MGUS). A bone marrow biopsy is mentioned in the note, but there is no rationale for NGS. The service was 
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 the GTC hematology profile have not been met. Therefore, we decided that the 
Plan does not have to pay for the Genomic Testing Cooperative (GTC) hematology profile (81455) provided on 
September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that a reasonable trial of the basic pump has been tried prior 
to ordering the segmented pump. 
 
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 device. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records in this case do not document lymphedema of the chest, trunk, or 
abdomen on physical examination of the patient. As the records do not document lymphedema of the chest, 
trunk or abdomen or a four-week trial and failure of a standard pneumatic compression pump, then it cannot be 
said that the enrollee has unique characteristics that would indicate a segmented pump over a standard pump.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission from July 22, 202, to July 25, 2022.
  
You asked the Plan to pay for an inpatient admission. You say that the requested Explanation of Benefits was 
not received within the allotted timeframe. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an inpatient admission from July 22, 202, to July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panel testing codes 87640, 87653, 87428, 87150, 87798, and 
87799 provided on May 20, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing panel cannot be unbundled and billed as individual components. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, this panel testing is considered a single procedural service, and the individual test 
components are not supported as separate and distinct procedural services from the test panel. Based on this 
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been 
met. Therefore, we decided that the Plan does not have to pay for panel testing codes 87640, 87653, 87428, 
87150, 87798, and 87799 provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service May 29, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says code 99233 is not supported by the medical record. The medical 
records do not support a detailed interval history and medical decision making of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination 
of care with other providers or agencies are provided consistent with the nature of the problem(s) and the 
patients and/or familys needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital 
floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee was a then, 73-year-old female with a history 
of chronic obstructive pulmonary disease, Asthma, hypertension, rheumatoid arthritis, Atrial fibrillation, and 
lung cancer status post right lower lobe lobectomy. She had had a previous admission for right 
hydropneumothorax requiring a chest tube. She presented on May 29, 2022, with weakness. The evaluation 
revealed anemia and persistent right loculated right hydropneumothorax. The review indicates that the 
evaluation did not include a detailed history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for date of service May 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four surgical placement of implant bodies (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says two implants have been approved the other two are denied for meeting your 
frequency limitations. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service has been reached. Therefore, we decided that the Plan does 
not have to pre-approve four surgical placement of implant bodies (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the annual wellness visit, and the primary 
care visit provided by an out-of-network provider on February 9, 2022. 
 
You asked the Plan to waive the deductible for the wellness visit and the primary care visit. You say that you 
think that this provider should be in-network. 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. Your 
contract with the Plan says that you must pay the full cost for covered out-of-network services until you have 
paid the $1500 out-of-network deductible, and the out-of-network deductible applies to the wellness visit and 
the primary care visit. 
 
 
 You have been asked to pay a $222.92 deductible for the wellness visit and the primary care visit ($126.92 
allowed amount + $96 allowed amount = $222.92 deductible). The items or services you asked the Plan to 
waive the deductible for were provided by an out-of-network provider. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $1500 out-of-network deductible which applies to annual 
wellness visits and physician/practitioner services, including doctors office visits. This cost sharing is a 
contractual obligation that had not been met at the time the wellness visit and the primary care visit were 
provided on February 9, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
the annual wellness visit, and the primary care visit provided by an out-of-network provider on February 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) Tooth #18 and 19. 
 
You asked the Plan to pre-approve dental services. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Surgical placement of implant 
body: endosteal implant (D6010) is not covered under the Plans dental benefits. 
 
  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 
surgical placement of implant body: endosteal implant (D6010) Tooth #18 and 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 8, 2022, to November 15, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford to pay 
this. 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 for inpatient hospital 
care, you must pay a $335 copayment per day for days 1 to 6; $0 copayment for days 7 to 90.  
 
You have been asked to pay $2,010 for inpatient hospital care ($335/day x 6 days = $2,010). This item/service 
falls within the inpatient hospital care 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 
inpatient hospital care provided from November 8, 2022, to November 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound of the kidneys and bladder received on 
November 10, 2022. 
 You asked the Plan to pay for the ultrasound.  The Plan denied your request. The Plan says the services should 
be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 9, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an ultrasound of the 
kidneys and bladder received on November 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 120 transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 120 transportation trips. You say that you need to get to your 
medical appointments. The Plan denied your request. The Plan says you are allowed up to 48 one-way trips per 
year. This request will exceed the benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 120 transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 29, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair (A9270). 
 
You asked the Plan to pre-approve a chair. You say that you need a recliner with a seat lift. You say that you 
cannot get out of your current chair without assistance. You say that you are otherwise bedridden. You also say 
that you need this chair. The Plan denied your request. The Plan says a chair is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a chair 
(A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service March 8, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billed code. The Plan 
denied your request. The Plan says code 99223 is not supported in the medical record because the records do 
not support medical decision making of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; a 
comprehensive exam; and medical decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the member is a 69-year-old female with a medical 
history including hypertension and hyperlipidemia who was admitted to the hospital on March 8, 2022, with a 
diagnosis of medication induced intractable nausea and vomiting and a distal left radial fracture requiring 
closed reduction. At the time of admission, she was medically stable and improved. There was no indication of 
decision making of high complexity, so the code is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vabysmo injection (codes J2777 and 67028). 
 You asked the Plan to pre-approve a Vabysmo injection. You say that you are interested in switching the 
enrollee to Vabysmo in the hope that you might be able to extend the interval between injections from three 
months to four months. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products, and has not tried any of the preferred agents. The Plan also says a 
rationale is not provided for use of the non-preferred product for safety or efficacy. 
 
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 a Vabysmo injection. Our reviewer says 
that the enrollee does not meet the coverage criteria for a Vabysmo injection. Our physician reviewer found the 
enrollee has not tried and failed the required drug. Our reviewer also found that the documentation does not 
support that Avastin would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vabysmo injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vabysmo injection (codes J2777 and 67028).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service September 2, 
2022. 
 You asked the Plan to pay for procedure code 11720. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 11720 is bundled into payment for code 11719. 
 
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service September 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is not safe for you to go home, and you need 
rehabilitation. You say you have been cleared by your doctors to go to rehabilitation. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 acute IRF admission and services.