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

 
We decided that the Plan does not have to pay for injections (62320) provided November 22, 2021. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided. 
 
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 injections (62320) provided November 22, 2021. have been met. No clinical records were provided to support that this service was medically 
necessary. The plan requested additional records and none were provided. Therefore, we decided that the Plan 
does not have to pay for injections (62320) provided November 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9502) provided from October 29, 
2021, through November 5, 2021. 
 
You asked the Plan to pay for home infusion therapy (S9502). You say that you are a contracted provider, and 
the enrollee falls under in-network status for the services. You say that the enrollee's eligibility should be 
reviewed, and the claim reprocessed under the correct network status. The Plan denied your request. The Plan 
says CPT code S9502 is not valid for Medicare billing purposes. 
  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 S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy (S9502) have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy (S9502) provided from October 29, 2021, through November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning (99497) provided on August 22, 
2021. 
  You asked the Plan to pay for the advance care planning (99497). You say that the services were medically 
necessary, and the medical records support the claim as originally submitted. You say that the physician 
provided this care in good faith and should be reimbursed for the services rendered. The Plan denied your 
request. The Plan says procedure code 99223 has been overturned and procedure 99497 is included with 
procedure code 99223. 
 
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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the advance care planning (99497) provided on August 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Artemis Comprehensive Cancer Panel (81163, 81437, 
81218, 81236, 81351, 81406, 81407) provided to the enrollee on September 27, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not demonstrate that the biomarkers would be used to assist in the 
management/treatment of 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Artemis Comprehensive Cancer Panel (81163, 81437, 81218, 81236, 81351, 81406, 81407) 
provided to the enrollee on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence panel (51+ genes) provided to 
the enrollee on November 16, 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 the request for a panel of 51 or greater genes is not reasonable or 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has metastatic Gleason 8 (4+4) prostate cancer tolerating ADT. A targeted genomic 
sequence panel (51+ genes) was provided to the enrollee on November 16, 2021. However, gene testing at this 
point in the clinical course of this patient with advanced metastatic prostate cancer would not result in a significant change in the patient's overall outcome and is not sufficiently supported in the documentation. 
Therefore, the targeted genomic sequence panel (51+ genes) requested will be considered not medically 
necessary based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a targeted genomic sequence panel (51+ genes) provided to the enrollee on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on October 4, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the obtained laboratory test. The review has determined that cardiac risk assessment genetic screening testing provided to the enrollee on October 4, 2021 was not medically 
necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on October 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health physical therapy services. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health physical therapy services. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found records do not 
support that the complexity of your conditions are such that the skills of a professional therapist are required to 
achieve further improvement or maintain your symptoms or functional status. Further utilization of the home 
exercise program with the assistance of the assisted living staff appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior segmental instrumentation (22845) provided on 
September 2, 2021. 
  You asked the Plan to pay for the anterior segmental instrumentation (22845). You say that you were not 
reimbursed for CPT code 22845 but expected reimbursement of $379.16. You say that the claim should be 
reviewed, and additional payment made accordingly. The Plan denied your request. The Plan says an 
appropriate modifier was not billed with this code edit. 
 
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 22845 
is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the anterior segmental instrumentation (22845) provided on 
September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies you purchased from April 6, 2021, to 
October 27, 2021, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that you feel as though you should be 
reimbursed for these supplies because the hospital said they were needed upon release. The Plan denied your 
request. The Plan says items purchased from an non-plan provider without authorization are 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 items and services from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the items at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for wound care supplies you purchased from April 6, 2021, to October 27, 2021, 
from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) for the 
enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met, as there is high risk prostate cancer. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the use of SBRT is predicated on the delivery of androgen deprivation therapy (ADT), which the 
enrollee is refusing. The LCD for this case specifies that it is only indicated for low- to intermediate risk 
disease. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xF Panel provided to the enrollee on November 21, 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 this testing is not Food and Drug Administration (FDA) approved. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that per National Comprehensive Cancer Network (NCCN) guidelines tumor/somatic molecular profiling 
is recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer 
therapy to identify uncommon mutations. Consider specifically testing for potentially actionable somatic 
findings including, but not limited to: fusions (ALK, NRG1, NTRK, ROS1, FGFR2, RET), mutations (BRAF, 
BRCA1/2, KRAS, PALB2), amplifications (HER2), microsatellite instability (MSI), and/or mismatch repair 
(MMR) deficiency. This patient with advanced pancreatic cancer meets this criteria. The service is 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 services have been met. Therefore, we decided that the Plan has to pay for 
the Tempus xF Panel provided to the enrollee on November 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased at Costco, an out-of-network 
provider, on December 21, 2021.  
You asked the Plan to pay for the eyeglasses. You say that the provider you went to was cheaper than the Plan 
provider. The Plan denied your request. The Plan says benefits for eyeglasses are only covered when you use a 
network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you receive them from a network provider.  You used a provider 
who is not in your Plan's vision network. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
eyeglasses you purchased at Costco, an out-of-network provider, on December 21, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xF Panel provided to the enrollee on April 21, 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 this testing performed was not Food and Drug Administration (FDA) approved. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found per the National Comprehensive Cancer Network (NCCN) Guidelines for  recommends molecular 
profiling for advanced prostate cancer. Tumor molecular and biomarker analysis may be used for treatment 
decision-making, including understanding eligibility for biomarker-directed treatments, genetic counseling, 
early use of platinum chemotherapy, and eligibility for clinical trials. Clinical trials may include established 
and/or candidate molecular biomarkers for eligibility. The service was reasonable and 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 services have been met. Therefore, we decided that the Plan has to pay for 
the Tempus xF Panel provided to the enrollee on April 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 
12, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service 
January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on November 8, 2021. 
 
You asked the Plan to pay for the drugs. You say that the claim should pay. The Plan denied your request. The 
Plan says this is not covered under the current benefit plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
29, 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 this is 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found next generation sequencing is indicated for many advanced cancers. There is no clinical information 
provided on this patient to determine medical necessity. The service is not reasonable or medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D biopsy provided to the enrollee on September 
27, 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 a review of the medical literature and clinical practice guidelines does not support the clinical 
utility of this testing, including computer-assisted immunohistochemistry, to predict cancer. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the American Society for Gastrointestinal Endoscopy includes WATS3D in its Standards of Practice 
Committee's guideline for the screening and surveillance of Barrett's esophagus. The clinical documentation in the case file does not support that the enrollee in this case has Barrett's esophagus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D biopsy provided to the enrollee on September 27, 2021.