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

 
We decided that the Plan does not have to pre-approve Affirma Gene Expression Classifier Genetic Test 
(81546). 
 
You asked the Plan to pre-approve genetic testing. You say that medical records have been submitted to 
support the request for reconsideration of the denial for genetic testing. The Plan denied your request. The Plan 
says for services to be covered, they must be medically necessary services, supplies, or drugs that are needed 
for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical 
practice. Therefore, the requested services are not reasonable and 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of nontoxic single thyroid nodule. An incidental thyroid nodule was 
seen on CT scan. The enrollee had a thyroid fine-needle aspiration (FNA) performed which demonstrated the 
presence of indeterminate thyroid FNA cytopathology described as atypia of undetermined significance. 
However, the available clinical documentation does not support that the need for thyroidectomy is unclear after 
consideration of clinical, imaging, and cytologic features. In addition, the case file does not include local 
institutional malignancy rates used for optimal extrapolation of results to thyroid cancer risk. The 
documentation is insufficient to support that the coverage criteria were met in this case, and that the genetic 
testing was medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Affirma Gene Expression Classifier Genetic Test (81546).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise equipment (A9300) provided on October 27, 
2022. 
 
You asked the Plan to pay for the equipment. You say that your doctor gave you a piece of exercise equipment 
for your foot. You also say that you feel this should be covered. The Plan denied your request. The Plan says 
the equipment is not covered. 
 
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 pay for the exercise equipment (A9300) provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 15, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported as billed. 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 
August 15, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81335 
and 81355.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner with lift mechanism. 
 
You asked the Plan to pre-approve a recliner with lift mechanism. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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. Medicare may 
only pay for seat lift mechanisms and does not covered recliners. In addition, there is no physician order or 
prescription for the requested item. Therefore, we decided that the Plan does not have to pre-approve a recliner 
with lift mechanism.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on October 25, 
2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were reported 
correctly. The Plan denied your request. The Plan says the code used to report the services provided is not 
supported in the medical record. 
 
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 G0483 is drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the medical records support 
that drugs from 14 drug classes were tested in this case. Based on this information, we decided that Medicare 
rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay 
for definitive drug testing (G0483) provided on October 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) with interpretation and report 
billed with code 93000 for December 14, 2021. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 93000 has an OPPS status indicator of M, 
which means it is not billable. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (EKG) with interpretation and report billed with code 93000 for December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
April 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99233 (1 unit) remains not supported. 
 
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 these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had reported altered 
mental status, syncope, essential hypertension, hyperlipidemia, and cardiomyopathy who was treated and 
discharged one week later. However, the provided documentation did not clearly show a detailed interval 
history, detailed examination, or medical decision making of high complexity for this admission to justify CPT 
code 99233. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested service. 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. Occlusal guard  hard 
appliance, full arch (D9944) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9944 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve occlusal 
guard  hard appliance, full arch (D9944).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure and was transferred to skilled nursing on March 10, 2023. The 
enrollees medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While enrollee may have a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32555-RT billed on September 23, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed diagnosis does not match the laterality 
modifier billed with code 32555-RT. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
32555-RT billed on September 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision chondrolaryngoplasty procedure rendered on 
July 29, 2022. 
 
You asked the Plan to pay for the surgery. You say that this is needed due to concerns about the look and feel 
of the neck. The Plan denied your request. The Plan says there is no documentation or evidence of an abnormal 
structure caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional 
defects, or 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has gender dysphoria. The record provided does 
not establish the the requested procedure is to correct a functional impairment or repair an abnormal structure 
caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or 
disease. The record provided is insufficient to establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pay for the revision chondrolaryngoplasty procedure rendered on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on October 27, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that transcutaneous electrical nerve stimulation 
(TENS) and supplies for chronic low back pain is only covered when the enrollee is enrolled in an approved 
clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was enrolled in a 
clinical study. Based on this information, we decided that Medicare rules for coverage of the electrical 
stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve ventilator. You say that the ventilator is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested ventilator is not medically necessary. 
 
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 ventilator. Our reviewer says that a 
home ventilator is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has severe chronic obstructive pulmonary disease (COPD). The reviewer found that 
the enrollee currently has a trilogy ventilator with documentation of regular usage. A recent arterial blood gas 
done while stable showed a partial pressure of carbon dioxide in arterial blood (PaCO2) of 45. The enrollee 
may benefit from continued nocturnal ventilatory support with BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. Therefore, the 
reviewer found that the requested home ventilator is not 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 ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27130 billed for June 13, 2022. 
 
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 procedure code 27130 is not supported. 
 
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 27130 is arthroplasty, acetabular and proximal femoral 
prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. 
 
We find that CPT code 27130 is not supported in the medical record. Specifically, there are no medical records 
for the date of service at issue to support that the services were performed as billed. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 27130 billed for June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (procedure code 99203) rendered on April 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99203 remains not supported. 
 
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 99203 is "Office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and low level of medical decision making. When 
using time for code selection, 30-44 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the record supports a medically 
appropriate history and exam, and medical decision making of low complexity. The complaint was an acute 
illness with systemic symptoms (moderate). The data involved ordering two tests (low). The risk and patient 
management included recommendations for over-the-counter remedies (low). This meets criteria in all 3 
elements of medical decision making to report 99203. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an office visit (procedure code 99203) rendered on April 28, 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.