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

 
We decided that the Plan does not have to pay for the CXbladder Detect test provided to the enrollee on 
January 6, 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 experimental and investigational procedures are not covered by the plan. 
 
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 CxBladder is considered experimental/investigational as a screening test for urothelial cancer. 
Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the 
results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-
stage and low-grade tumors. 
 
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 the CXbladder Detect test provided to the enrollee on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis services (81345) provided on September 8, 
2021. 
 You asked the Plan to pay for the gene analysis services. You say that these services were medically reasonable 
and necessary. The Plan denied your request. The Plan says this code as not billed with an appropriate modifier 
to allow for payment. 
 
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 81345 
is a column II code to column I code 0089U. 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 gene analysis services (81345) provided on September 8, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 4 to January 25, 
2022. 
 
You asked the Plan to pay for psychotherapy services. You say that the provider at issue is a licensed Medicare 
provider. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
January 4 to January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a front wheel walker with contact guard assistance and is supervision to stand-by 
assist for transfers. Provided records do not document a significant decline in your functional status to 
necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Records do not document that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found as the enrollee responded to antihypertensives quickly while in the 
emergency department and a new stroke was ruled out, it was not expected that the enrollee would require 
hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on March 18, 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 outpatient services provided on March 18, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on October 31, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided medical records to support 
the service at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (99100) provided on October 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network benefit coverage for an 
esophagogastroduodenoscopy to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve in-network benefit coverage for an esophagogastroduodenoscopy to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
in-network benefit coverage for an esophagogastroduodenoscopy to be provided by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on October 14, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that these services are supported and medically 
necessary. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that providers must report services with the correct POS code. For services rendered to a patient who 
is registered inpatient or an outpatient of a hospital, the correct POS code, regardless of where the face-to-face 
service occurs, is that of the appropriate inpatient or outpatient POS code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this code was billed with an 
inpatient POS code (21) but based on the records provided and the enrollees claim history, the enrollee was 
outpatient status at the time of these services. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay 
for initial hospital care (99223) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge services provided on December 21, 
2021. 
 
You asked the Plan to pay for the observation discharge services. You say that this should be paid. The Plan 
denied your request. The Plan says code 99217 can only be paid to the provider who billed for the initial and/or 
subsequent observation services.  
The Plan must follow Medicare rules. Medicare rules say that only the physician who orders hospital 
observation services and is responsible for the patient during the observation stay can bill the observation 
codes.  
 
We looked at the file and Medicare rules. In this case, the provider who billed for the observation discharge 
services is not the same provider who ordered hospital outpatient observation services and was responsible for 
the patient during his/her observation care. Based on this information, we decided that Medicare rules for 
coverage of the observation discharge services have not been met. Therefore, we decided that the Plan does not 
have to pay for the observation discharge services provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a walk-in shower installation provided on 
October 28, 2021. 
 
You asked the Plan to reimburse you for a walk-in shower installation. The Plan denied your request. The Plan 
says a walk-in shower is not covered by your health Plan. 
 
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 reimburse you for a walk-in shower installation provided on 
October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions provided from September 8, 2021, through October 19, 2021. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions. The Plan 
denied your request. The Plan says the Plan does not cover this expense and remains denied. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) 
provided from September 8, 2021, through October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing coded as 81241 and 81291 
provided March 10, 2021. 
 
You asked the Plan to pay for the pathology testing. You say that please find the attached documents, review, 
and reconsider the claim for payment. The Plan denied your request. The Plan says the service does not meet 
Medicare NCD/LCD criteria. 
 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 find that CPT codes 81241 and 81291 are not supported in the medical record. Specifically, 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for 
coverage of the pathology testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the molecular pathology testing coded as 81241 and 81291 provided March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established 
patient (92014), determination of refractive state (92015) and scanning computerized ophthalmic diagnostic 
imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided 
January 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam, eye refraction and ophthalmic diagnostic imaging. You say that 
you have always gone to this doctor and did not realize the services would not be covered. The Plan denied 
your request. The Plan says these services are not covered when provided OON. 
 
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 provided in-network. 
 
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the eye exam, eye refraction and ophthalmic diagnostic imaging have not been met. Therefore, we decided that 
the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with 
initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014), 
determination of refractive state (92015) and scanning computerized ophthalmic diagnostic imaging, posterior 
segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided January 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper lid blepharoplasty for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for this procedure for both of the eyes. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee's complaints and findings, and the visual fields 
meet the coverage criteria as established by LCD L34528. The enrollee has bilateral dermatochalasis of the 
upper eyelids with unspecified visual field defects. 
 
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 pre-approve upper lid blepharoplasty for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 14, 
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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 drug testing services provided to the enrollee on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair, mobile or stationary, with fixed arms 
(E0163) purchased December 7, 2021. 
 
You asked the Plan to pay for the commode chair. You say that you were told you needed a toilet commode to 
assist you in using the facilities at home. The Plan denied your request. The Plan says equipment was 
purchased from a provider not certified for Medicare. 
 
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 indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the commode chair, mobile or stationary, 
with fixed arms (E0163) purchased December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray interpretation (code 71045-26) billed for date 
of service December 11, 2021. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says the medical records do not support payment of this 
code. 
 
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 71045-26 is x-ray of the chest, single view.  We looked at 
the medical records you submitted in support of your appeal.  The medical records only reference a computed 
tomography (CT) combo of the head and cervical spine without contrast and a CT angiography of the head and 
neck with and without contrast.  There is no mention of a chest x-ray anywhere in the medical records you 
provided.  
 
We find that CPT code 71045-26 is not supported in the medical record. Therefore, we decided that the Plan 
does not have to pay for the chest x-ray interpretation (code 71045-26) billed for date of service December 11, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. While you may benefit from physical and occupational therapy, your rehabilitation needs can be addressed at a 
low intensity alternate setting such as in a skilled nursing facility. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.