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

 
We decided that the Plan does not have to pay for procedure codes 88341 & 88342 billed for date of service 
October 20, 2021. 
 You asked the Plan to pay for procedure codes 88341 & 88342. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for codes 88341 & 88342 is bundled into 
payment for code 88361. 
 
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 codes 
88341 & 88342 are column II codes to column I code 88361. 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 codes 88341 & 88342 billed for date of 
service October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99497) provided on April 5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate". 
 
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 use of code 99497 is 
not supported by the records provided. Our reviewer found that the procedure report does not include enough 
information to confirm advanced care planning was performed. The procedure report documents "70 minutes 
with greater than 50% of the time spent at the patient's beside counseling the patient in a face-to-face meeting and coordinating care between other health providers. The goals of care conversation occurred between 
between 1030 hours and 1100 hours". The documentation does not include sufficient documentation to support 
explanation and discussion of advance directives, to include: having conversations with family members and/or 
other loved ones about what is wanted in the event of a life-threatening illness or injury, as well as, the time 
spent performing advanced care planning. 
 
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 the services (99497) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PCD (CPT code(s): E0652 and E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Review of the file shows the records do not show the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen which has remained unresponsive to all other 
therapies. Therefore, we decided that the Plan does not have to pre-approve the PCD (CPT code(s): E0652 and 
E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollee's back pain. 
 
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 the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services (97802, 97803). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you have high cholesterol, 
and you need assistance with your meal choices. The Plan denied your request. The Plan says MNT is only 
covered if a member has a diagnosis of diabetes or kidney disease. You do not have either and you do not meet 
criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services (97802, 97803).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, 
ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when 
performed (CPT code 33274). 
 
You asked the Plan to pre-approve the service. You say that the enrollee needs the pacemaker to improve their 
life expectancy. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The enrollee's records do not show 
that they are enrolled in a CMS approved coverage with evidence development (CED) study. Therefore, we 
decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless 
pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, 
ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when 
performed (CPT code 33274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on 
February 21, 2022. 
 
You asked the Plan to pay for the F1CDx 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. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the specimen was collected 
on January 17, 2022. The billed date of service is February 21, 2022. This means there is no documentation to 
support the testing with the billed date of service. Based on this information, we decided that Medicare rules 
for coverage of the F1CDx testing have not been met.  
  
 
Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing 
provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that you have issues with taking pain medication 
and massage therapy greatly helps your pain management day to day. The Plan denied your request. The Plan 
says massage therapy is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 13, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from August 
13, 2021, to August 15, 2021. The Plan says, per Medicare guidelines, the provider must bill Original Medicare 
for the services rendered on August 13, 2021. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination services coded 
G0402, and the hospital outpatient clinic visit coded G0463 provided on February 18, 2022. 
 
You asked the Plan to pay for the initial preventive physical examination services, and the hospital outpatient 
clinic visit. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are 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 CPT code. 
 
We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, when two 
evaluation and management services are billed with the same revenue code on the same of service, these 
services must be billed with condition code G0. Review of the file shows that these codes were not billed with 
the correct condition code. Based on this information, we decided that Medicare rules for coverage of the initial preventive physical examination services, and the hospital outpatient clinic visit have not been met. Therefore, 
we decided that the Plan does not have to pay for the initial preventive physical examination services coded 
G0402, and the hospital outpatient clinic visit coded G0463 provided on February 18, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not 
been 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 Lupron Depot. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the Plan requires a trial of drug Eligard before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drug. There is no documentation provided indicating that the Plans 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Lupron Depot (J9217).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records with 
treatment notes showing the ordering physicians intent that this testing be performed. 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 the lab services provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, and 
81407. 
 
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 the services are not billed correctly. 
 
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 
March 22, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 
81328, 81335, 81355, and 81407.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be performed by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services the 
enrollee needs. 
 
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 
the office services to be performed by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion/stabilization services. 
 
You asked the Plan to pre-approve SI joint fusion/stabilization services. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says imaging of the sacroiliac joint with 
computed tomography (CT) or magnetic resonance imaging (MRI) has not been performed, nor has an x-ray of 
the pelvis. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint fusion/stabilization services are covered 
when advanced imaging criteria have been met.  
 
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 SI joint fusion/stabilization services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
computed tomography (CT) or magnetic resonance imaging (MRI) of the SI joint in the chart. Therefore, at this 
time, the request is deemed not medically reasonable or 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 SI joint fusion/stabilization services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve sacroiliac (SI) joint fusion/stabilization services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on April 18, 
2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair, with or without wheels, any size 
(E0240) and a reaching/grabbing device, any type, any length (A9281). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. Additionally, the rules say that grab bars are not covered because they are 
considered self-help items that are not primarily medical in nature. 
 
While these items may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. 
Therefore, we decided that the Plan does not have to pre-approve a shower chair, with or without wheels, any 
size (E0240) and a reaching/grabbing device, any type, any length (A9281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure complete vanilla nutrition shake. 
 
You asked the Plan to pre-approve Ensure nutrition shake. You say that the enrollee has had significant issues 
with dietary intake due to dysphagia. She was referred to a dietician to assist with nutrition and 
recommendations to improve intake. It was per this consult that Ensure Complete was recommended 3 times 
daily to provide supplemental nutrition while treatment plans and goals were being developed to improve 
nutrition by mouth. The goal is to prevent her from the need of a feeding tube being placed. The Plan denied 
your request. The Plan says the rules say that Medicare does not pay for nutritional supplements. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure complete vanilla nutrition shake.