Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided July 2, 2016, through July 4, 
2016. 
 
You asked the Plan to pay for inpatient hospital care provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says care was not 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 inpatient hospital care provided have been met. Specifically, missing medical records. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided July 2, 2016, through July 4, 2016.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 16, 2022, billed with 
codes 81231, 81232, 81291, 83106, 81355, 81335, 0031U, 0032U, 0033U, 81479, 81407, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 16, 2022, billed with codes 81231, 81232, 81291, 83106, 81355, 81335, 0031U, 0032U, 0033U, 81479, 
81407, and 81238.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on September 
21, 2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not covered by the 
MolDX program or was not reported according to MolDX guidelines. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Therefore, we decided that the Plan does not have to 
pay for DecisionDx-SCC testing (0315U) provided on September 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-vascular extremity ultrasound (code 76882) provided 
on October 18, 2022. 
 
You asked the Plan to pay for the non-vascular extremity ultrasound. The Plan denied your request. The Plan 
says this claim is a duplicate of a previously processed claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were processed 
by the Plan on November 7, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the non-vascular extremity ultrasound have not been met. 
Therefore, we decided that the Plan does not have to pay for a non-vascular extremity ultrasound (code 76882) 
provided on October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the enrollee's records do not show the needs for complex rehabilitation that require 
frequent evaluation by a rehabilitation doctor, services needed can be provided safely in other settings, a skilled 
nursing facility. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services at a 
lower level of 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 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit provided on August 6, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that this service was not billed with an appropriate diagnosis. 
 
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. Review of the file shows that the Plan has denied this service due to not being 
billed with an appropriate diagnosis. The Plan did not cite Medicare rules that specifically state that the 
diagnosis billed (Z11.1, defined as encounter for screening for respiratory tuberculosis) cannot be billed with 
this service. While the case file submitted did include an insert from the Medicare Claims Processing Manual, 
the Plan did not indicate why this excerpt applies to the billing at issue. No other denial rationale was provided. 
This means the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
emergency department visit provided on August 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for May 9, 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. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for 
procedure code 88360 billed for May 9, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a short-latency somatosensory evoked potential study (code 95938), 
intraoperative neurophysiology procedures (code 95940) and electromyography procedures (code 95861) 
provided on September 16, 2021. 
 
You asked the Plan to pay for the short-latency somatosensory evoked potential study, intraoperative 
neurophysiology procedures and electromyography procedures. You say that you are the only provider that 
provided these services. The Plan denied your request. The Plan says that we were previously billed by and 
paid another provider for these services. 
 
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 proof that another provider billed the 
Plan for these services and was paid for these services. Therefore, we decided that the Plan has to pay for a 
short-latency somatosensory evoked potential study (code 95938), intraoperative neurophysiology procedures 
(code 95940) and electromyography procedures (code 95861) provided on September 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 20930. You say that kindly have the claims processed for 
maximum payment at the earliest. The Plan denied your request. The Plan says procedure code 20930 is 
considered bundled and not separately payable. 
 
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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1686, L2624) provided October 12, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this device was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a relevant medical records which support medical necessity for the supplies 
provided in this case. The records provided do not note the need for this item or how it would be used. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L1686, L2624) provided October 12, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration of 
payment services provided to the member. The Plan denied your request. The Plan says this is past the allowed 
12 month timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that a party may request a contractor reopen and 
revise its initial determination or redetermination within 1 year from the date of the initial determination or 
redetermination for any reason. 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. The case file shows that you requested the Plan reopen 
its initial determination issued on September 4, 2020. The Plan received this request for reopening on October 
20, 2022. Your request did not include a valid good cause explanation for submitting the reopening request 
beyond 1 year from the date of the initial determination. Your request for reopening was not to correct a 
clerical error on which that determination was based. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on August 7, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found since the enrollee is on 
anticoagulants and has a history of cirrhosis those comorbidities provide factors that indicate closer 
surveillance than every year.  The request for CTA of the abdomen and pelvis should be approved. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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 lab services (81479) provided on December 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was 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 (81479) provided on 
December 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA. 
 
You asked the Plan to pre-approve CTA. You say that the enrollee has a moderate to high pretest probability of 
coronary disease based on clinical risk factors. You say that a CTA will help rule out if there are any 
obstructive coronary artery disease. The Plan denied your request. The Plan says a CTA is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CTA scans are covered only when they are 
medically necessary.  
 
 
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 CTAscan. Our reviewer says that CTA 
is not medically necessary. Our physician reviewer found that asymptomatic individuals with moderate to high 
risk of coronary artery disease do not meet the criteria for a CTA as the first line test. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CTA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on August 24, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you are requesting reimbursement for the cost of the 
eyeglasses after your cataract surgery. You say you believed a portion of the cost of the lenses would be 
covered. The Plan denied your request. The Plan says the benefit has exhausted.  
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. The Plan covers these services with up to $100 every year for non-Medicare covered prescription 
eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 towards the eyeglasses on August 
24, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses provided on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, periapical first film, periapical 
additional, pulp vitality tests, pulpal debridement, panoramic film, cone beam computed tomography (CT) 
scan, and incomplete endodontic therapy (D0140, D0220, D0230, D0460, D3221, D0330, D0364, D3332) 
provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the pulp vitality tests, pulpal debridement, cone beam CT scans, and 
incomplete endodontic therapy denied correctly as they do not fall within your dental benefits. Periapical first 
film and the periapical additional were included in the completed services. 
 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, periapical first film, 
periapical additional, pulp vitality tests, pulpal debridement, panoramic film, cone beam computed tomography 
(CT) scan, and incomplete endodontic therapy (D0140, D0220, D0230, D0460, D3221, D0330, D0364, D3332) 
provided on November 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve strabismus surgery with an out-of-network (OON) 
provider. 
 You asked the Plan to pre-approve strabismus surgery with an OON provider. You say that the network 
provider the Plan referred them to currently only sees pediatric patients. The Plan denied your request. The 
Plan says they have two network providers who are able to perform adult strabismus correction. The Plan says 
that the provider that the appellant states only sees pediatric patients, does see adults for the enrollee's 
diagnosis. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 strabismus surgery with an OON 
provider. Our reviewer says that the criteria for OON coverage have not been met. Our physician reviewer 
found the Plan is offering adequate care to meet the enrollee's medical needs through referral to the two in-
network providers they have cited. The in-network providers that the Plan has referred the enrollee to are able 
and available to perform adult strabismus surgery to repair the enrollee's condition of hypertropia. There is 
nothing that would make it medically necessary for the enrollee to see an OON provider. The Plan has shown 
that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's 
condition. The case notes included documentation showing the Plan reached out to confirm that the two 
network providers they have referred the enrollee to are able to perform adult strabismus correction surgery. 
The provider that the appellant claims only sees pediatric patients, does see adults for the enrollee's diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of strabismus surgery with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve strabismus surgery with an out-of-network (OON) provider.