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

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, 51 or more genes 
(81455) billed for date of service January 11, 2022. 
 
You asked the Plan to pay for code 81455. You say that the test was ordered by the treating physician because 
the test results were needed to help determine the course of treatment for this enrollee. The Plan denied your 
request. The Plan says that this testing does not meet Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology services are coverable if the test 
is medically necessary, is approved by the FDA, and results of the testing directly impact treatment or 
management of the patient. 
 
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 code 81455. Our reviewer says that the 
targeted genomic sequence analysis panel, 51 or more genes (81455) provided meets Medicare's medical 
necessity criteria. Our physician reviewer found the patient had Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater 
genes, interrogation for sequence variants and copy number variants or rearrangements, if performed for patient 
with diagnosis of Myelodysplastic syndrome, unspecified Targeted myeloid Next Generation Sequencing 
(NGS) assay can detect Copy Numbered Variants (CNVs) with high concordance compared with MDS FISH 
panel for common MDS CNVs as well as genome-wide CNVs by conventional chromosome analysis. A 
targeted myeloid NGS assay could identify both mutations and CNVs in patients with myeloid malignancies, 
rendering this approach highly suitable for clinical application. Therefore, the records show that the enrollee 
meets the medically necessary criteria for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 81455 have been met. Therefore, we decided that the Plan has to pay for 
the targeted genomic sequence analysis panel, 51 or more genes (81455) billed for date of service January 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on May 18, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you believe the claim was billed 
incorrectly. The Plan denied your request. The Plan says you were charged this cost sharing 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 $45 
copayment for each exam to diagnose and treat diseases or conditions of the eye.  
 
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the Vision Care 
benefit category. 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 an eye exam provided on May 
18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 3, 2022. 
 
You asked the Plan to pay for code 99285. You say that code 99285 was supported by the medical record. The 
Plan denied your request. The Plan says code 99285 is not supported in the medical record. Instead, the service 
met criteria for code 99284. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.  
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported in the medical record. Our reviewer found the enrollee was a then, 65 year-old female 
who presented to the emergency room on January 3, 2022 with low back pain and lower abdominal pain. She 
was evaluated with a history and physical, laboratory studies, computed tomography (CT) scan of the lumbar 
spine and a CT scan of the abdomen/pelvis. She was treated with intravenous (IV) fluids, IV Toradol, IV 
MSO4, and IV Zofran. CT scan of the lumbar spine revealed lumbar stenosis/disc bulging and CT of the 
abdomen/pelvis was negative. She was discharged home with Norco/Robaxin and primary care follow-up. 
There was no medical decision making of high complexity. Therefore, the Plan was justified in downgrading 
this service to 99284. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device (code E0470) and humidifier 
(E0562). 
 
You asked the Plan to pre-approve the respiratory assist device and humidifier. You say that this device is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory assist devices coded with E0741 are 
not covered for patients with obstructive sleep apnea.  These devices are only potentially coverable for patients 
with one of the following conditions: restrictive thoracic disorders, severe chronic obstructive pulmonary 
disease, Central Sleep Apnea or Complex Sleep Apnea syndrome, or hypoventilation syndrome. 
 
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 respiratory assist device and 
humidifier. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have obstructive sleep apnea (OSA) and chronic 
obstructive pulmonary disease (COPD) and were using continuous positive airway pressure (CPAP) with oxygen which was effective for the OSA. You began to notice black particles, and the device was subject to 
recall. You currently do not have a CPAP device. You recently had a COPD exacerbation.  However, there are 
no pulmonary function tests to confirm COPD and assess severity. There is no arterial blood gas readings 
documenting chronic carbon dioxide retention.  Therefore, there is no demonstration of need for the requested 
device. 
 
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 respiratory assist device and humidifier have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a respiratory assist device (code E0470) and humidifier 
(E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that you are requesting 
reconsideration with supporting documentation. The Plan denied your request. The Plan says the requested 
SEPCT does not meet the requirements for approval. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity of carrying out a 
radionuclide stress test. The enrollee has no cardiac symptoms. The enrollee has right bundle branch block and 
thus there is no documentation that the ECG shows an uninterpretable pattern. There is no evidence provided 
that would support the need for radionuclide stress testing. In summary, there is insufficient documentation to 
support the medical necessity for the requested cardiac stress testing in the enrollees clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique 
(78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you more for the eye exam, refraction, and the eyewear 
you received on October 13, 2021. 
 You asked the Plan to reimburse you more for the eye exam, refraction, and the eyewear. You say that the 
company from which you purchased these eyeglasses would not take insurance.  You stated that you paid 
$850.18 and want to be reimbursed this amount. The Plan denied your request. The Plan says you have been 
reimbursed the full billed amount for the eye exam and refraction.  You have been reimbursed $158.94 (from 
the provider) for the eyewear you received.  The Plan agreed that you were owed an additional $41.06 towards 
this eyewear, and the Plan will be reimbursing you this amount.  The Plan has stated that you are not entitled to 
any further reimbursement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. Specifically, your Plan contract says that you have a $200 allowance for supplemental eyewear every 
year.  Members are responsible for all costs over and above the allowance amount. You have already been 
reimbursed $158.94 by the provider, and the Plan has agreed to reimburse you an additional $41.06.  This is a 
total of $200, which is the annual eyewear allowance under your Plan.  You have now exhausted this benefit 
and you are responsible for any costs associated with eyewear beyond this $200 benefit. That is why you are 
not entitled to further reimbursement for the eyewear you received.  
 
Therefore, we decided that the Plan does not have to reimburse you more for the eye exam, refraction, and the 
eyewear you received on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on February 4, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (0037U) provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an urgent care visit and an 
electrocardiogram (EKG) provided on May 9, 2022. 
 
You asked the Plan to waive the copayments for the urgent care visit and EKG. You say that the visit was a 
medical necessity. You say that you were not able to see your PCP. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $45 
copayment for each office visit for urgently needed services with a provider other than you PCP. 
 Your contract with the Plan also clearly says that you must pay a $10 copayment for X-rays, laboratory and 
other diagnostic tests per service date. 
 
You have been asked to pay a $45 copayment for the urgent care visit and a $10 copayment for the EKG. The 
urgent care visit falls within the Urgently Needed Services benefit category. The EKG falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for the visit is 
$55. 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 copayments for an urgent care visit and an electrocardiogram (EKG) 
provided on May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service April 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health occupational therapy visits. 
 
You asked the Plan to pre-approve 4 additional home health occupational therapy visits. You say that you 
would like these visits to be completed per the family's request. The Plan denied your request. The Plan says 
the records do not support the need for additional home visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 4 additional home health occupational 
therapy visits. Our reviewer says that the additional home health occupational therapy visits are not medically 
necessary. Our physician reviewer found the enrollee is independent in function and able to maintain with 
repetitive exercise. The enrollee currently has no deficit requiring skilled input. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional home health occupational therapy visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 4 additional home health occupational 
therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
January 10, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not told about the 
copayment at the time of service. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $40 
copayment for physical therapy in-person visits.  
 
You have been asked to pay a $40 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation Services benefit category. 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 physical 
therapy (PT) services provided on January 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 15, 2021, to December 22, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not told about the 
copayment at the time of service. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $40 
copayment for physical therapy visits.  
 You have been asked to pay a $40 copayment for each of the PT services, for a total of $80. The PT services 
fall within the Outpatient Rehabilitation Services benefit category. 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 
copayments for physical therapy (PT) services provided from December 15, 2021, to December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on February 
10, 2022. 
 
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code 99152. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation (D9243 and D9239), therapeutic parenteral drugs 
(D9612), and an endosteal implant (D6010), provided by an out-of-network provider on Marcy 22, 2022. 
 
You asked the Plan to pay for sedation, therapeutic parenteral drugs, and an endosteal implant. You say that 
you say that you need these implants to eat high fiber foods. The Plan denied your request. The Plan says the 
rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for sedation 
(D9243 and D9239), therapeutic parenteral drugs (D9612), and an endosteal implant (D6010), provided by an 
out-of-network provider on Marcy 22, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory drug testing (G0483, 80307) provided on March 1, 2022 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent and prior authorization was not obtained.

 
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 laboratory drug testing (G0483, 80307) provided on March 1, 2022 by an out-of-network (OON) provider.