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

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service April 1, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve LITT of lesion (CPT code 61736). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that the procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the available evidence in the medical literature suggests that LITT is a relatively safe and 
effective option for the treatment of patients with recurrent brain tumors. The proposed treatment regimen, to 
include LITT, has been determined to be medically reasonable and necessary 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 the surgical services have been met. Therefore, we decided that the Plan has to 
pre-approve LITT of lesion (CPT code 61736).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vivity lens you received on February 24, 2022. 
 
You asked the Plan to pay for the lens. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the Vivity lens you received 
on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88341, 88342, 88360, 88377, and 
88381) provided on January 27, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, 88377, and 88381. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (88341, 88342, 88360, 88377, and 88381) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supply allowance used with a therapeutic CGM device (K0553) 
provided April 1, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that you are submitting medical records 
along with CMS, WOL form and delivery details in order to process the claim. The Plan denied your request. 
The Plan says that this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. in this case specific records or information was required to substantiate the Plans 
denial. The required information was missing from the original file. The original file received only consisted of 
3 pages of the RBDF. A request for the case file was sent to the Plan on October 12, 2022 and the Plan sent 
medical records which was received on October 13, 2022. The case file was still missing specific information 
to be able to proceed with the case. Another request for information was sent to the health plan on October 19, 
2022 with a due date of October 20, 2022. As of the date of this letter, the plan has not responded to our request 
and/or submitted the required information Therefore, we decided that the Plan has to pay for the supply 
allowance used with a therapeutic CGM device (K0553) provided April 1, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that the additional requested therapy generally is not accepted as specific and 
effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy 
and the documentation does not reveal that you require the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. There has been 
instruction in a home exercise program. You do not require additional skilled therapy beyond what was 
approved by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve six additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive medicine counseling provided on  
February 25, 2022. 
 
You asked the Plan to pay for preventive medicine counseling. The Plan denied your request. The Plan says 
preventive medicine counseling is not a covered benefit. 
 
The Plan contract does not cover preventive medicine counseling. 
 
We looked at the file and the Plans rules. Based on this information, we decided that Medicare rules for 
coverage of preventive medicine counseling have not been met. Therefore, we decided that the Plan does not 
have to pay for preventive medicine counseling provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services rendered on April 1, 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 that the provider should not have billed diagnosis code R06.02. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that diagnosis code R06.02 should not have been billed; 
however, there is no explanation to state why code 99291 is not payable as billed. The Plan has not provided 
any documentation or valid Medicare rules to support that code 99291 is not payable as billed. Therefore, we 
decided that the Plan has to pay for the critical care services rendered on April 1, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77067-26 billed for date of service June 1, 2021. 
 
You asked the Plan to pay for code 77067-26. You say that the patient had multiple exams on this date of 
service. 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 July 20, 2021. 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 code 77067-26 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 77067-26 billed for date of service June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on February 23, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81241) provided on April 29, 2022. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 genetic tests are not considered to be 
clinically effective and therefore, are not medically necessary.  
 
We looked at the file and Medicare rules. The testing performed is considered not medically necessary and is 
non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81241) provided on April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on April 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you want to appeal the amount being charged. The Plan 
denied your request. The Plan says As a member of our plan, the enrollee must use network providers. If the 
enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee 
will be responsible for the entire cost. 
 
 
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 x-ray provided on April 12, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that a more complex drug screening was 
provided. The Plan denied your request. The Plan says the code is integral to the primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. The testing described by billed code 83789 is considered specimen 
validity testing which is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on May 
5, 2022. As such, the claim was billed with the incorrect date of service. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 22, 2021. 
 You asked the Plan to pay for the testing services. You say that clinical evidence supports broad-panel testing. 
The Plan denied your request. The Plan says the test is not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The test at issue is not FDA approved. The panel test was not billed with a 
single code as required. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing 
provided on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81206, 81162, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404, and 84494. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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 
March 8, 2022, billed with codes 81206, 81162, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404, 
and 84494.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision refraction received on May 31, 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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover eye exams for the purpose of 
prescribing, fitting, or changing eyeglasses or contact lenses for refractive error onlyr.  
 
The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does 
not have to pay for vision refraction received on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an initial right above knee prosthesis. 
 
You asked the Plan to pre-approve an initial right above knee prosthesis. 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 follows Medicare rules. Medicare rules say that when an above knee initial prosthesis (L5505) or an 
above knee preparatory (L5560, L5570, L5580, L5590, L5595, L5600) prosthesis is provided, prosthetic 
substitution and/or additions of procedures and components are covered in accordance with the functional level 
assessment except for codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, and 
L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5790, L5795 which will 
be denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an initial right above knee prosthesis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that you are a K2 level ambulator. The requested prosthesis is appropriate for a 
K2 level ambulator. Therefore, it 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 an initial right above knee prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an initial right above knee prosthesis.