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

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2021, billed 
with codes 81238, 81220, 81226, 81225, 81335, 81227, 81230, 81355, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
September 27, 2021, billed with codes 81238, 81220, 81226, 81225, 81335, 81227, 81230, 81355, 81241, 
81291 and 81240.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-help/peer services provided on March 23, 2022. 
 
You asked the Plan to pay for self-help/peer services. You say that you believe the services should be covered 
under the mental health benefit. The Plan denied your request. The Plan says the self-help/peer services in 
dispute and require a diagnosis of Opioid dependence and the diagnosis on the claim in dispute do not meet 
coverage requirements. 
 
The Plan contract covers Opioid Treatment Program Services. 
 
We looked at the file and the Plans rules. The file shows that the diagnosis on the claim does not meet the 
Plans coverage requirements. Therefore, we decided that the Plan does not have to pay for self-help/peer 
services provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of procedure code 34713 billed on February 11, 2022. 
 
You asked the Plan to pay for 2 units of procedure code 34713. You say that the requested medical records 
fully support the billing, and the claim should be reprocessed to allow payment. The Plan denied your request. 
The Plan says CPT code 34713 has an MUE value of 1 but 2 units were billed. 
  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 2 units of 
procedure code (34713) have not been met. Therefore, we decided that the Plan does not have to pay for 2 units 
of procedure code 34713 billed on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on February 1, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from March 16, 2021, to April 14, 2021. 
 
You asked the Plan to pay for home health services. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan has denied in this case because, for home health services 
billed longer than a 30-day episode of care, the claim needs to be split up. However, the Plan has not provided 
evidence that the dates of service at issue are part of a continuous episode of care. It is the Plan's responsibility 
to substantiate its denial. In this case, the denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for home health services provided from March 16, 2021, to 
April 14, 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 the laboratory services rendered on January 11, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 11, 2022.
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 you are appealing the denial of LTACH 
admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about your condition you don't meet all the requirements. 
 
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 you were admitted to the acute care hospital with acute respiratory failure due to 
worsening lung nodules and consolidation following poor compliance with treatment for pulmonary 
mycobacterium avium complex. You were treated with mechanical ventilation support and antibiotics. The 
course was complicated by acute kidney injury, anemia, and bradycardia, treated with fluids, transfusion, 
vasopressors, and diuresis. PEG and trach were placed.  
 
 Recent notes describe you as likely not being able to wean from vent but is more stable. You are receiving 
appropriate care at the present setting. You do not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. 
 
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 infectious agent detection by nucleic acid (DNA or RNA) 
respiratory virus 3-5 targets (87631) provided January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please find the attached documents that 
contain the physician progress notes, history notes, lab reports and lab orders and process the claim 
accordingly. The Plan denied your request. The Plan says LCD Part B missing or invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at this the file, and Medicare rules. The Plan confirmed with outreach to the provider's office that 
there was no order made for genetic testing from their office for this enrollee. 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 infectious agent detection by nucleic acid (DNA or RNA) respiratory 
virus 3-5 targets (87631) provided January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72128 billed for date of service March 6, 
2022. 
 
You asked the Plan to pay for procedure code 72128. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 72128 is bundled into payment for 
code 72129. 
 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 72128 
is a column II code to column I code 72129. 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 procedure code 72128 billed for date of service March 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest provided on March 11, 2022. 
 
You asked the Plan to pay for a radiologic examination, chest. 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 a radiologic examination, chest provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 17, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan. 
 
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 subsequent nursing facility care provided on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E00466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized with 
acute on chronic hypercarbic respiratory failure. There is a diagnosis of COPD, but there are no pulmonary 
function tests to confirm and establish severity. You do not have thoracic restrictive disease or neuromuscular 
disease. You may benefit from bipap during sleep, which can provide the AVAPS mode. But Medicare does 
not cover a home ventilator when used as bipap. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E00466).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport provided on December 22, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee was not in hospice at the time 
of transport and the claim should be reprocessed. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 14, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport provided on December 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on March 28, 2022. 
 
You asked the Plan to pay for the ophthalmological services. 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 ophthalmological services provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedures on the prostate provided on 
December 15, 2021. 
 
You asked the Plan to pay for surgical procedures on the prostate. You say that the patient had no choice for an 
in-network assistant. The Plan denied your request. The Plan says the services were rendered by a provider who 
is credentialed as a Registered Nurse Registered Nurse First Assistant and is non-participating with the Plan's 
network. This provider specialty does not have the capacity to bill directly for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for surgical procedures on the prostate provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the positron emission tomography (PET) 
scan with concurrently acquired computed tomography (78815) and the Fluorodeoxyglucose diagnostic, per 
study dose (A9552) provided on March 22, 2022. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
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 clearly says that you must pay a $65 
copayment for provider and professional services and a 50% coinsurance for advanced imaging services 
rendered by an out-of-network provider.    
You have been asked to pay $960.56 ($65 copayment + $895.56) for the advanced imaging service rendered by 
an out-of-network provider. This amount includes a $65 copayment for the provider and professional services 
provided. Additionally, this includes the Plan allowed amount of $1,791.13 x 50% coinsurance= $895.56 for 
the advanced imaging service provided. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the positron 
emission tomography (PET) scan with concurrently acquired computed tomography (78815) and the 
Fluorodeoxyglucose diagnostic, per study dose (A9552) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 2, 2022. 
 
You asked the Plan to pay for physician's services. 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 physician's services provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified (87798) provided February 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that if the ordering provider is in-network, your 
pathology services can also be considered for payment even if the lab is out of network. You hereby request 
reconsideration of this claim for payment. The Plan denied your request. The Plan says with the information 
provided you cannot determine how the enrollee came to the servicing provider, or whether the services are 
medically necessary. 
 
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 infectious agent detection by 
nucleic acid (DNA or RNA), not otherwise specified (87798) provided February 14, 2022. have been met. The 
Plan made multiple attempts to obtain records from the provider without success. Therefore, we decided that 
the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA), not otherwise 
specified (87798) provided February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 4, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 4, 2022.