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

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services. 
 
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 laboratory services provided on January 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on June 20, 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 the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided on 
June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 2, 2021, to August 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $275 
copayment per day for days 1-5 and $0 per day for days 6-90 for in-network inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-5 and $0 per day for days 6-90 for inpatient 
hospital care. The total allowed amount is $550 ($275 x 2 days = $550). However, you are only being asked to 
pay $275 which is less than the required amount. 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 copayment for 
inpatient hospital care provided from August 2, 2021, to August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says as there has been little to no growth, further therapy is not indicated. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy and the documentation does not reveal that the patient's requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. You can transition to an independent home exercise program and follow up with your 
treating physician.  
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 24, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 not supported in the medical record. Specifically, the documentation supports 
that the enrollee was tested for 13 drug classes on this date of service. This means that 22 or more drug classes 
were not tested; therefore, code G0483 is not supported. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0483 provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for presbyopia correcting function of intraocular lens (code V2788) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the presbyopia correcting function of intraocular lens. You say that you would 
like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says 
that routine eye services must be rendered by an in-network provider. 
 
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 not provided consistent information with regard to the 
network status of the rendering provider. The Plan has not provided the rule showing why this service would 
not be covered as this service is not a routine vision benefit. Therefore, we decided that the Plan has to pay for 
presbyopia correcting function of intraocular lens (code V2788) provided on January 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provided DecisionDx-Melanoma testing provided on 
June 13, 2022. 
 
You asked the Plan to pay for the provided DecisionDx-Melanoma testing. You say that the provided 
DecisionDx-Melanoma testing provided on June 13, 2022, was medically necessary. The Plan denied your 
request. The Plan says the provided DecisionDx-Melanoma testing provided on June 13, 2022, was 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 pay for the provided DecisionDx-Melanoma testing. 
Our reviewer says that the provided DecisionDx-Melanoma testing provided on June 13, 2022, was not 
medically necessary. Our physician reviewer found the use of gene expression profiling (GEP) testing 
according to specific AJCC-8 melanoma stage (before or after sentinel lymph node biopsy (SLNB)) requires 
further prospective investigation in large, contemporary data sets of unselected patients. Prognostic GEP testing 
to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging 
procedures. On an individual basis, the likelihood of a positive SLNB may be informed by the use of optimized 
multivariable nomograms/risk calculators and ongoing investigation of GEP tests. Use is not supported by the 
National Comprehensive Cancer Network (NCCN) Guidelines to guide therapy for surveillance. The service 
was not reasonable or medically 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 provided DecisionDx-Melanoma testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the provided DecisionDx-Melanoma testing provided on June 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 15, 2022, billed 
with multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were billed correctly. 
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 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 
February 15, 2022, billed with multiple codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0463 and G0402 provided on May 17, 2022. 
 
You asked the Plan to pay for codes G0463 and G0402. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes G0463 and G0402 are not supported in the medical record. Specifically, these codes 
were billed with the same revenue code on the same date of service. Two evaluation and management codes 
billed with the same revenue code on the same date of service must be billed with condition code G0 This claim was not billed with the appropriate condition code. Based on this information, we decided that Medicare 
rules for coverage of codes G0463 and G0402 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes G0463 and G0402 provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Lynch Syndrome Panel. 
 
You asked the Plan to pay for the Invitae Lynch Syndrome Panel. You say that given the enrollee's personal 
and strong family history of colon cancer, the provider recommends genetic testing to rule out Lynch syndrome The Plan denied your request. The Plan says this test has not passed the TA for the MolDX program and the 
family history does not meet the requirements for hereditary testing. We are not able to approve this test. 
 
The Plan must follow Medicare rules. Medicare rules say that the test must have satisfactorily completed a 
Technical Assessment (TA) by Molecular Diagnostic Services Program (MolDX) for the stated indications of 
the test. 
 
We looked at the file and Medicare rules. This test is not listed in the MolDX database as a covered test. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of the Invitae Lynch Syndrome Panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the Invitae Lynch Syndrome Panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 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. 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 these 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 the laboratory services rendered on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthotic occlusive device (D7880). 
 
You asked the Plan to pre-approve an orthotic occlusive device. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an orthotic occlusive device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an orthotic occlusive device (D7880).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatectomy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve prostatectomy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services can be provided by a network provider. 
 
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 
prostatectomy services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services (PSR) and targeted 
case management (TCM). 
 
You asked the Plan to pre-approve psychosocial rehabilitation services and targeted case management. You say 
that psychosocial rehabilitation services and targeted case management are medically necessary. The Plan 
denied your request. The Plan says psychosocial rehabilitation services (PSR) and targeted case management 
(TCM) are not medically necessary and do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 psychosocial rehabilitation services and 
targeted case management. Our reviewer says that psychosocial rehabilitation services and targeted case 
management are not medically necessary. Our physician reviewer found you are being treated for Major Depressive Disorder, Recurrent, Moderate. Based on review the records provided, it is noted that you have 
depressive symptomatology but is able to perform activities of daily living. There is no documented PHQ 9 
depression scale or testing for depression. You do not have any suicidal or homicidal thoughts and do not 
require inpatient care for psychosocial rehabilitation services and targeted case management. Based on review 
the records provided you do not require inpatient care for the treatment utilizing psychosocial rehabilitation 
services and targeted case management but could be treated on an outpatient basis by your doctor along with 
therapy and therefore is not considered reasonable or medically 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 PSR and TCM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve psychosocial rehabilitation services (PSR) and targeted case management (TCM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep number bed and set up services received on 
June 16, 2021. 
 
You asked the Plan to pre-approve the sleep number bed and set up services. You say that you need this bed to 
raise your legs. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 pre-approve the sleep number bed and set up services received on June 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 90662, G0008, G0402, and G0463 provided on 
November 29, 2021. 
 
You asked the Plan to pay for codes 90662, G0008, G0402, and G0463. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 codes 90662, G0008, G0402, and G0463 are not supported in the medical record. 
Specifically, when multiple medical visits occur on the same date in the same revenue centers, condition code 
G0 should be billed on the claim. This condition code was not billed on the claim. Based on this information, 
we decided that Medicare rules for coverage of codes 90662, G0008, G0402, and G0463 have not been met. Therefore, we decided that the Plan does not have to pay for codes 90662, G0008, G0402, and G0463 provided 
on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 99213 is bundled into 
payment for code 95117. 
 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 99213 
is a column II code to column I code 95117. 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 99213 billed for date of service May 24, 2022.