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

 
We decided that the Plan does not have to pay for lab services provided on November 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the enrollee's physician ordered this test to help 
determine the best course of treatment for the enrollee's specific cancer. 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 November 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Drugs Mounjaro Inj 2.5/0.5. 
 
You asked the Plan to pre-approve Drugs Mounjaro Inj 2.5/0.5. You say that the enrollee has been unable to 
take any other medications beside Mounjaro. The Plan denied your request. The Plan says subcutaneous 
injection that can be self-administered is covered by pharmacy drug benefit. 
 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 pre-approve Drugs Mounjaro Inj 2.5/0.5.  
 
Benefits for Drugs Mounjaro Inj 2.5/0.5 may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing (81345) provided on November 4, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was billed 
with an invalid DEX Z-code. 
 
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 argues that the claim was billed with an invalid DEX Z-code. 
However, the submitted claim form shows that this line item was billed with DEX Z-code ZBBIA. The Plan 
has not provided documentation showing that this code is incorrect, nor has it shown which code would be 
appropriate in this case. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the testing (81345) provided on November 4, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology procedure, Tempus HRD cancer test 
(81479) 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says that the request is not medically necessary because this test is not an FDA 
approved or cleared diagnostic test or certified by the New York State Department of Health's Clinical 
Laboratory Evaluation Program (CLEP) review standards. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has metastatic bladder cancer. The requested test was 
performed by the provider as an "add on" test to the Tempus xT genetic test to guide the enrollee's therapy. The 
Tempus xT assay uses saliva and blood for germline DNA, and formalin-fixed paraffin-embedded (FFPE) 
tissue (solid tumors and lymphoma), bone marrow/peripheral whole blood (heme) for tumor deoxyribonucleic 
acid (DNA) and ribonucleic acid (RNA). The review has determined that items/services at issue in this case are medically reasonable and 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the unlisted molecular pathology procedure, Tempus HRD cancer test (81479)  
 
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.