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

 
We decided that the Plan does not have to pay for a chiropractic manipulative treatment provided on May 16, 
2022, by an OON provider. 
 
You asked the Plan to pay for a chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial for services rendered to the enrollee. 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 a chiropractic manipulative treatment provided on 
May 16, 2022, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
February 12, 2022, to February 13, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service February 12, 2022, to February 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 24, 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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until May 17, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the surgical services rendered on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on May 9, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 chiropractic treatment provided on May 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a synthetic bone graft during approved lumbar fusion 
surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is considered investigational. 
 
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 requested services. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows 
synthetic bone graft during fusion procedures to be an effective or safe treatment for the noted pathology. As 
noted, more comparative studies are needed to evaluate the efficacy of bone graft substitutes overall. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested synthetic bone graft during the approved lumbar fusion 
surgery, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a synthetic bone graft during approved lumbar fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the medical services provided from August 7, 
2021, to February 20, 2022, outside of the United States. 
 
You asked the Plan to reimburse you for the medical services. You say that you were not satisfied with the 
services you provided. You also say that these services should be covered. The Plan denied your request. The 
Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the medical services provided from 
August 7, 2021, to February 20, 2022, outside of the United States have not been met. Specifically, there was 
no documentation provided to support that the services you received were urgent or emergent. Therefore, we 
decided that the Plan does not have to reimburse you for the medical services provided from August 7, 2021, to 
February 20, 2022, outside of the United States.
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 enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says criteria for this level of care have 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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The patient's medical status does not require intensive physician and nursing oversight in an IRF. While the 
patient may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that the patient requires or can tolerate this therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of neurostimulator electrode array; 
sacral nerve (64581). 
 
You asked the Plan to pre-approve these services. You say that this is necessary because you have had 
incontinence for years. The Plan denied your request. The Plan says that your request is not medically necessary because your records show you have not had a trial of sacral nerve stimulation with 50% or greater 
improvement through test stimulation. 
 
The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation can be covered for the 
treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention if the patient 
demonstrates a 50% or greater improvement through test stimulation. 
 
We looked at the file and Medicare rules. The file does not indicate you have had a trial of sacral nerve 
stimulation with 50% or greater improvement through test stimulation. 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 open implantation of neurostimulator electrode array; sacral nerve (64581).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87641, 87798, 88305 and 
88312 provided March 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this claim has denied in error. Please see the 
attached supporting documentation and reprocess the claim for payment. The Plan denied your request. The 
Plan says the provider is not eligible to perform the services billed. 
 
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 laboratory services coded as 87641, 
87798, 88305 and 88312 provided March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 23, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says services from 
non-participating providers are not covered unless preauthorized. 
 
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 physician's services provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided February 
19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the Tempus HRD test was ordered by the 
Plan's in-network provider. Please find a copy of all available medical records you have obtained from the 
referring provider. The Plan denied your request. The Plan says services do not meet coverage requirements. 
 
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 code 81479 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 specimens 
were collected on March 11, 2021 and March 25, 2021, rather than the billed date of service February 19, 2022. 
The date of service for a clinical laboratory test or the technical component of physician pathology service must 
be the date the specimen was collected. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
unlisted molecular pathology (81479) provided February 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOneCDx (F1CDx) testing provided on December 2, 
2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that the service was not billed with a Unique Test 
Identifier. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to this case as it is not valid for the 
Provider's headquarter billing state of Pennsylvania. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have not been met. Therefore, we decided that the Plan has to pay for the FoundationOneCDx (F1CDx) 
testing provided on December 2, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for hereditary peripheral neuropathy panel testing (81448) 
provided May 2, 2022. 
 
You asked the Plan to pay for the genetic laboratory testing. You say that the enrollee's physician ordered 
genetic testing due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The 
Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Results of the testing must directly impact treatment or management 
of the Medicare beneficiary, for the test to be covered by Medicare. This test will not change any management 
in this enrollee and therefore is not medically appropriate or necessary. Invitae comprehensive neuropathies 
panel is not covered by Medicare per DEX diagnostics. Based on this information, we decided that Medicare 
rules for coverage of the genetic laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for hereditary peripheral neuropathy panel testing (81448) provided May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LINX procedure. 
 
You asked the Plan to pre-approve LINX procedure. You say that you disagree with 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. 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 LINX procedure. 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 gastroesophageal reflux disease. The records indicate that the 
enrollee has improved symptoms with baking soda and is not on maximally doses proton pump inhibitors. The 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LINX procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LINX procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 12, 2021, billed with 
codes 81225, 81230, 81240, 81241, 81291 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided medical records to 
support the services billed. The Plan denied your request. The Plan says rules for payment for genetic testing 
have not been met. 
 
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 12, 2021, billed with codes 81225, 81230, 81240, 81241, 81291 and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device. 
 You asked the Plan to pre-approve an intermittent limb compression device. You say that this device is 
medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage 
of an intermittent limb compression device have not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. The rules state that a four-week trial of conservative therapy demonstrating failed 
response to treatment is required before a pneumatic compression device will be 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 an intermittent limb compression 
device. Our reviewer says that the requested intermittent limb compression device is not medically reasonable 
and necessary. Our physician reviewer found that you are a 40-year-old female with a diagnosis of 
lymphedema. Based on the medical records provided there is no documentation that the pneumatic 
compression device at issue in this case meets Medicare criteria for medically reasonable and necessary. 
Specifically, the provided records do not document a 4-week trial and failure of regular and compliant use of an 
appropriate compression bandage system or compression garment to provide adequate graduated compression, 
regular exercise and leg elevation. 
 
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 intermittent limb compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an intermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic screening (0031U, 0032U, 0033U, 
81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, 81355) provided on April 6, 2022. 
 
You asked the Plan to pay for cardiovascular genetic screening. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is 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, cardiovascular genetic screening, 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 cardiovascular genetic screening (0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 
81306, 81328, 81335, 81355) provided on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lesion destruction services provided on March 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the service was separate from her previous 
procedure. The Plan denied your request. The Plan says the service is included within the global surgery 
package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 17000 is destruction (e.g., laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion. 
 The file shows that CPT code 17000 was provided during the global surgery period of a previous procedure. 
We find that CPT code 17000 was not billed with a modifier indicating an unrelated procedure during the 
original postoperative period. 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 lesion 
destruction services provided on March 18, 2022.