Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care services (99223, 99233) billed for dates of 
service from March 29, 2022, to March 31, 2022. 
 
You asked the Plan to pay for hospital care services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 29, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for hospital care services have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital care services (99223, 99233) billed for 
dates of service from March 29, 2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight genetic testing services (81479) provided on May 
23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that facts underlying in the appeal align with LCD 
L38394 GeneSight Pharmacogenomics testing and should be considered for payment. The Plan denied your 
request. The Plan says prior authorization from the Plan was not obtained for this OON provider. The Plan also 
says this test is considered investigational and /or experimental. 
 
 
 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 GeneSight genetic testing services (81479) 
provided on May 23, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 provided on February 24, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that the medical records support the billing of 
code 99239. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99239. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
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 procedure code 99239. Our reviewer says that the medical records do not support the billing of code 99239. Our reviewer found there is no documentation of a complex 
hospital discharge note that would support the billing of code 99239. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99239 provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided from March 2, 2020, to 
September 30, 2020. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says these claims were not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until June 28, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for laboratory services provided from March 2, 2020, to September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for sleep apnea to be provided by a 
non-Medicare enrolled provider. 
 
You asked the Plan to pre-approve the oral appliance. You say that it is noted that you are a Medicare supplier 
and have been paid by Medicare for services. The Plan denied your request. The Plan says the provider does 
not show up in the Medicare supplier directories. No written evidence of Medicare participation has been 
submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records does not support that this provider is enrolled in the Medicare 
program. We requested that the provider submit additional information to confirm participation status, but no 
documentation was returned. Without clear evidence showing the provider is eligible for Medicare payment, 
we find that the denial is supported. Therefore, we decided that the Plan does not have to pre-approve an oral 
appliance for sleep apnea to be provided by a non-Medicare enrolled provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on June 27, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that the medical records support the billing of 
code 99214. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99214. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 procedure code 99214. Our reviewer says that the medical 
records do not support the billing of code 99214. Our reviewer found the documentation available for review 
does not support medical decision of moderate 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 procedure code 99214 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99214 provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and should be 
allowed for payment. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the procalcitonin testing (84145) provided on September 21, 2022. 
 
You asked the Plan to pay for the procalcitonin testing. You say that this testing is experimental or 
investigational. The Plan denied your request. The Plan says that this testing was medically necessary. 
 
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 pay for the procalcitonin testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the procalcitonin test has been validated as useful in determining whether a patient has 
bacterial infection.  The result of the test supports decision making on whether to prescribe antibiotics.  Since 
there was a question of bacterial infection as a cause of this enrollee's bronchitis, it was reasonable in this 
circumstance, in supporting the decision not to prescribe antibiotics. 
 
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 procalcitonin testing have been met. Therefore, we decided that the Plan has 
to pay for the procalcitonin testing (84145) provided on September 21, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this ventilator will improve the enrollee's 
quality of life. The Plan denied your request. The Plan says criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says that this device is not medically reasonable and necessary. Our physician reviewer found that the requested 
device is not a true ventilator, because it is not capable of providing full ventilatory support. Its intended use is 
during activity, and not to treat nocturnal hypoventilation and CO2 retention. There is inadequate evidence of 
the safety and effectiveness of this device in the treatment of chronic obstructive pulmonary disease (COPD). 
The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427, A0427) provided 
on September 21, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that these services were coded correctly. The 
Plan denied your request. The Plan says this claim is missing the necessary secondary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that one of a specified group of secondary diagnosis 
codes must be reported in addition to a primary diagnosis for ambulance transportation claims.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance transportation have not been met. Specifically, this claim does not include one of the 
four secondary diagnosis codes required for ambulance transportation claims. Therefore, we decided that the 
Plan does not have to pay for ambulance transportation services (A0427, A0427) provided on September 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory services provided on July 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and laboratory services provided on 
July 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power arm brace (MyoPro) (L8702). 
 
You asked the Plan to pre-approve MyoPro. You say that MyoPro is the enrollee's best opportunity for 
regaining meaningful use of the left upper limb. The Plan denied your request. The Plan says medical studies 
haven't proven this item is helpful for the treatment of the enrollee's health problem. 
 
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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power arm brace (MyoPro) (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service November 
29, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that the medical records support the medical 
necessity of this service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder repair surgery. 
 
You asked the Plan to pre-approve shoulder repair surgery. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is no supporting documentation that the enrollee has 
tried conservative treatments, and the enrollee has deltoid atony which is a contraindication for this surgery. 
 
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 shoulder repair surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. No compelling rationale is presented or extenuating circumstance 
noted to support the medical necessity of this request as an exception to guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder repair surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder repair surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is 
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 a MyoPro orthotic device. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's brachial plexus condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve long-
term outcomes for the enrollee. There is insufficient evidence in the literature that this device will increase 
participation in bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have osteoarthritis of the left knee. The documentation does not support that you have tried and 
failed Euflexxa and Synvisc-One. The documentation does not support that Euflexxa and Synvisc-One would 
likely be less effective and/or likely have adverse effects. Therefore, you do not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve the PVA procedure. You say that it is felt that this treatment is needed. The 
Plan denied your request. The Plan says the compression fracture is not acute enough to warrant this treatment. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for PVA treatments is limited to those 
caused by either acute or subacute compression fractures.  
 
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 PVA procedure. Our reviewer says 
that the PVA procedure is not considered reasonable and necessary based on LCD criteria. Our physician reviewer found the documentation indicates that the fracture is likely older than 12 weeks. There is no evidence 
to support an acute or subacute fracture. 
 
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 PVA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous vertebral augmentation (PVA).