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

 
We decided that the Plan does not have to pay for laboratory services coded as 87338, 87798, 83520, 82656, 
83631, 82274, 87177, 87209, 82705 and 89055 provided on April 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please see the attached documents and 
process the claim accordingly. 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 laboratory 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 laboratory services coded as 87338, 87798, 83520, 82656, 83631, 82274, 
87177, 87209, 82705 and 89055 provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 17, 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 procedure code 0239U 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 0239U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including 
substitutions, insertions, deletions, select rearrangements, and copy number variations. 
 
We find that CPT code 0239U is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. 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 the laboratory 
services rendered on March 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on April 11, 2022. 
 
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded as 0090U provided June 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the myPath Melanoma test is a covered 
Medicare benefit under Local Coverage Decision MoIDX: myPath Melanoma Assay (L37879) and should be a 
covered benefit for the enrollee. The Plan denied your request. The Plan says 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, the CPT Code Manual definition of code 0090U is oncology (cutaneous melanoma), mRNA gene 
expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie, benign, indeterminate, malignant. 
 
We find that CPT code 0090U is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
May 19, 2022, rather than the billed date of service June 15, 2022. 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 pay for the genetic testing coded as 0090U provided June 15, 2022.
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 you were independent before your hospitalization. 
You say that you want to return to being independent. You say that you are eager to participate in the 3 hours 
of daily aggressive rehabilitation that an IRF will offer. You say that you would not get this necessary level of 
care at a nursing home. The Plan denied your request. The Plan says the records do not show that you need an 
intensive team. The Plan says that your needs can be provided safely in other settings. 
 
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 infected wounds of the leg and was transferred to skilled nursing on September 20, 2022. The 
enrollee's medical problems are stable. 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 the medical record supports 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on March 10, 2022, by an OON provider. 
 
You asked the Plan to pay for an x-ray. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an x-ray provided on March 10, 2022, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for laboratory services, an outpatient hospital clinic 
visit, and the deductible for an office visit provided from February 7, 2022, to April 11, 2022. 
 
You asked the Plan to waive the coinsurance for laboratory services, an outpatient hospital clinic visit, and the 
deductible for an office visit. You say that your medical procedure was pre-approved so you should not be 
getting a denial. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for laboratory services, an outpatient hospital clinic visit, and a specialist 
office visit provided from February 7, 2022, to April 11, 2022.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $10.03 
coinsurance for outpatient hospital clinic visit and laboratory services provided from February 7, 2022, to April 
11, 2022. We also did not see where the contract says that the enrollee must pay a $103.50 deductible for a 
specialist office visit provided from February 7, 2022 to March 7, 2022, and a $26 deductible for a specialist 
office visit provided on April 11, 2022. This means that the Plan did not follow Medicare rules for disclosure of 
cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for laboratory 
services, an outpatient hospital clinic visit, and the deductible for an office visit provided from February 7, 
2022, to April 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus and diphtheria immunization rendered on May 
16, 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 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 codes 90471 has an OPPS status indicator of Q1, 
meaning it has a packaged payment when billed with a code with an OPPS status indicator of V. This code was 
billed with code 99283, which has an OPPS status indicator of V. Code 90714 has an OPPS status indicator of 
N, meaning payment is packaged into other services. Therefore, we decided that the Plan does not have to pay 
for the tetanus and diphtheria immunization rendered on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on March 31, 2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for the enrollees condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
provided on March 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on April 6, 2022. 
 
You asked the Plan to pay for drug testing.. You say that this was billed correctly. The Plan denied your 
request. The Plan says that the records do not show that 22 or more classes were tested. 
 
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, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that 23 classes 
were tested: Alcohol biomarkers; Alkaloids, not otherwise specified; Amphetamines; Antiepileptics, not 
otherwise specified; Barbituates; Benzodizepines; Buprenorphine; Cannabinoids, natural; Cocaine; Fentanyls; 
Heroin metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Methylphenidate; 
Opiates; Opioids and opiate analogs; Oxycodone; Phencyclidine; Skeletal muscle relaxants; Stimulants, 
synthetic; Tapentadol; and Tramadol. Based on this information, we decided that Medicare rules for coverage 
of drug testing. have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) 
provided on April 6, 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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you say that being diabetic you cannot be poking 
yourself 3-4 times a day due to not being able to heal like everyone else. You need this CGM so that you know 
where your sugars levels are after eating and taking your medication. The Plan denied your request. The Plan 
says you do not meet coverage criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this device is needed. The 
Plan denied your request. The Plan says this is considered an experimental procedure. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Food and Drug Administration (FDA) indications for the requested procedure include 
implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal 
stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has 
multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including 
the planned level of implantation at L4-5). FDA contraindications include spinal instability, scoliosis, obesity, 
and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of 
spinal instability on flexion/extension films. FDA contraindications include spinal instability, scoliosis, obesity, 
and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films.  
 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the enrollee does not have a diagnosis/condition that meets criteria 
for the requested services and the requested Vertiflex Superion interspinous device at L4-5, in this case, is not 
medically reasonable or 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been in the hospital to 
long and needs the rehabilitation in a LTACH. The Plan denied your request. The Plan says the criteria for 
LTACH admission has not been met and the enrollee's medical needs are being met at the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the patient appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and appropriate for a lower level of care. The patient does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the patient requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 5, 2022 billed with 
codes 81194, 81301, 81455, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says multiple unbundled codes cannot be billed for a single panel. 
 
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 
May 5, 2022 billed with codes 81194, 81301, 81455, & 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided on May 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 lab services 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 lab services (83789) provided on May 11, 2022.