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

 
We decided that the Plan does not have to pay for the DecisionDx-SCC genomic test (0315U) provided August 
17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the DecisionDX-SCC test was denied in 
error, and you are requesting it to be reprocessed and paid. The Plan denied your request. The Plan says the 
DecisionDx-SCC test is considered experimental and investigational as there is insufficient evidence that the 
test results provide accurate, clinically actionable information resulting in improved patient outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. 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 DecisionDx-SCC genomic test (0315U) provided August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutches (billed with code E0114-KX) for date of service 
December 9, 2021. 
 
You asked the Plan to pay for the crutches. You say that you added modifier KX to the claim, so it should be 
paid. The Plan denied your request. The Plan says you did not bill the crutches with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that The rules state that claims must specify whether 
equipment is rented or purchased. Providers should append the appropriate modifier to indicate rental or 
purchase. In this case, you only billed with the KX modifier indicating that the enrollee met Medicare coverage 
criteria for the crutches.  You failed to bill with a modifier indicating whether or not the crutches were rented 
(modifier RR) or purchased (modifier NU or UE). Without this required modifier, payment for the crutches 
provided cannot be determined since the fee schedule has different rates for rentals vs. purchase.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the crutches have not been met. Therefore, we decided that the Plan does not have to pay for the 
crutches (billed with code E0114-KX) for date of service December 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 
23, 2022, to August 31, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the enrollee was not enrolled in hospice on the dates 
of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
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 August 13, 2022. 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 skilled nursing 
facility (SNF) care provided from August 23, 2022, to August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 13, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 13, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aimovig injection. 
 
You asked the Plan to pre-approve Aimovig injection. You say that the requested drug is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aimovig injection.  
 Benefits for Aimovig injection may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of the intraosseous basivertebral 
nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that up until know you have received shots 
in the back to relive pain. The pain in you back has made it so that you cannot do anything without pain. The 
Plan denied your request. The Plan says the requested Intracept procedure is considered experimental and 
investigational as the procedure has not been shown to be safe and effective for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies with 
imaging guidance, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 10, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 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 99497 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 
procedure code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99497 billed for date of service July 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT scan. 
 
You asked the Plan to pre-approve a cone beam CT scan.. You say that you really need to have this service due 
to teeth issues. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Cone beam CT scan is not 
covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested cone beam CT scan is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for 
the requested device. The Plan denied your request. The Plan says the requested device is not medically 
necessary. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the provided records document a 
diagnosis of chronic respiratory failure due to chronic post-COVID conditions. No pulmonary function studies 
or imaging studies have been provided confirming thoracic restrictive disease or obstructive pulmonary 
disease. The provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a bi-level 
positive airway pressure (BiPAP) device with AVAPS and a back-up rate.  Ventilators used to provide BiPAP 
therapy are not considered reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022, billed with 
codes 81201-90, 81162-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, and 81351-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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 
June 30, 2022, billed with codes 81201-90, 81162-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 
81321-90, and 81351-90.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided to the enrollee from 
January 19, 2022, to January 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99233 (1 unit) remains not supported. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care service provided by a healthcare provider, requiring a medically appropriate history and/or examination 
and a high level of medical decision making and the total time spent on the encounter is at least 50 minutes." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review indicates that the 
records did not support the use of CPT 99233 in this case. The records did not support that there was a detailed 
interval history. The records did not support that there was a detailed exam. The records did not support that the decision making was of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. 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 subsequent hospital care provided to the enrollee from January 19, 2022, to January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 1, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 1, 
2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for presumptive drug testing (80307). We decided that the Plan does not 
have to pay for validity testing (83789).  
 
You asked the Plan to pay for laboratory services (80307, 83789) billed for date of service June 22, 2022. You 
say that these services were necessary and should be paid. The Plan says that code 83789 for validity testing is 
not separately payable, and another presumptive drug testing service from the 80305-80307 code set was 
already billed for this enrollee for this date. Only one code from this range may be reported per date of service. 
 
We decided that the Plan has to pay for presumptive drug testing (80307).  
 
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 provided no evidence to show that another 
presumptive drug testing service (codes 80305-80307) was billed and paid for this enrollee for this date of 
service. The Plans denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for 
presumptive drug testing (80307).  
 
We also decided that the Plan does not have to pay for validity testing (83789). 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing (83789). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-CS billed for date of service 
December 31, 2021. 
 
You asked the Plan to pay for code 99213-CS. You say that this claim should have been paid in full with no 
member liability because the services were related to COVID-19. The Plan denied your request. The Plan says 
this claim is a duplicate of a previously paid claim and was correctly denied. You did not provide medical 
records to show that the services were related to COVID-19, so there is no evidence that cost sharing should 
not have applied. 
 
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 items/services at issue were 
reimbursed by the Plan on February 14, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 99213-CS have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99213-CS billed for date of 
service December 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary knee 
osteoarthritis. The enrollee has not tried and failed the Plan's required drugs, Durolane, Monovisc, or Synvisc-
One. The records do not show that the required drugs would be less effective or cause adverse effects; 
therefore, Gel-One is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-One.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility care. 
 
You asked the Plan to pre-approve additional SNF care. You say that the enrollee had hip surgery and needs 
the continued care. The Plan denied your request. The Plan says anything over 100 days of service is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from September 23, 
2022, through January 8, 2023. The Plan has covered 100 days of SNF care.  
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve SNF care beyond 100 days.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77014 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 77014. You say that you believe payment was denied incorrectly. 
The Plan denied your request. The Plan says payment for code 77014 is bundled into payment for code 77290. 
 
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 77014 
is a column II code to column I code 77290 with a modifier indicator of 0. The column II code is therefore not payable. 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 77014 billed for date of service May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion provided to the enrollee on 
August 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 22830-59-51 is not supported by the medical records submitted. 
 
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 22830 is "Exploration of spinal fusion." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 22830 is not documented in 
the operative note. There is not enough adequate documentation of fusion exploration for the diagnosis of 
failure of fusion. 
 
We looked at this coder's review, the file, and Medicare rules. 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 exploration of spinal fusion provided to the enrollee on August 10, 2022.