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

 
We decided that the Plan does not have to pre-approve Tempus Gene Panel test (CPT code(s): 81321, 81352, 
81162, and 81307) provided on September 30, 2021. 
 
You asked the Plan to pre-approve the testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee does not have a family history of breast, ovarian, pancreatic or prostate 
cancer, nor is the enrollee noted to be of an ethnicity associated with a higher prevalence of pathogenic 
mutations; therefore, the Plan is unable to approve your request as the testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the Tempus xG - Hereditary Cancer Panel is medically reasonable and necessary for the enrollee in this case and will impact the management and outcomes of the 
enrollee. It has not been shown that the testing meets but does not exceed the medical need in this case, and that 
the testing is at least as beneficial as existing and available medically appropriate alternatives. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tempus Gene Panel test (CPT code(s): 81321, 81352, 81162, and 81307) provided on 
September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 6, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis, in situ hybridization (quantitative or 
semi-quantitative), manual, per specimen; each multiplex probe stain procedure (CPT code 88377-59) provided 
on October 26, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported, and this code is included in CPT code 81342. The Plan states the 
documents received do not support that the procedure or service was distinct or independent from other 
services performed; therefore, the use of the 59 modifier 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.  
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria for modifier -59. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 
specimen; each multiplex probe stain procedure (CPT code 88377-59) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 24, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens are received from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. This claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on July 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81263, 82232, 80053, 
and 36415) provided on September 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
It was confirmed that the denials assessed on procedure codes 36415-87340 were appropriate. This is because 
the submitted documentation indicates that the member received a single set of labs on this date of service and 
payment for these procedure codes was already issued on your initial claims for this date of service. 
Additionally, it was confirmed that the denials assessed on procedure codes 88271 and 88275 were done so 
appropriately. This is because Medicares National Correct Coding Initiative (NCCI) Edits list 81263/88271 
and 81263/88275 as coding pairs with a modifier indicator 1. If clinical circumstances warrant separate 
reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate 
indication, the appropriate modifier may be appended to differentiate between the services provided. However, 
procedure code 81263 was billed on a claim, and payment was already issued for this procedure code on that 
claim. It is also important to note that these procedure codes were billed without a modifier on your claims for 
this date of service. 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 laboratory services 
(CPT code(s): 81263, 82232, 80053, and 36415) provided on September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, head or brain; with contrast material(s) (CPT code 
70460) provided on January 8, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70460 
is a column II code to column I code 0042T. 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 CT, head or brain; with contrast material(s) (CPT code 70460) 
provided on January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82656, 82705, 83520, 
and 83631) provided on August 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 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 laboratory 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 the laboratory services (CPT code(s): 82656, 82705, 83520, and 83631) 
provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 22, 2020, to September 30, 2020. 
 
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 the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 the case file does not contain 
documentation of a major joint replacement or spinal surgery. This means the "A" in AEMD1 is not supported. 
Additionally, while J18.9 - Pneumonia, unspecified organism (History of) is listed for this enrollee, the case 
file does not contain documentation of a current diagnosis of pneumonia. This means that the "M" in AEMD1 
is not supported in the medical records. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from September 22, 2020, to 
September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1845). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the orthosis is necessary. The Plan denied 
your request. The Plan says your request is not medically necessary because your records do not show you have 
had a recent injury or surgery of the knees or objective evidence of knee instability. 
 
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 knee orthosis. Our physician 
reviewer found the provided documentation does not show objective instability of this joint or report of plans 
for or recent surgery that might warrant bracing of the joint at this time. Therefore, without sufficient support 
made for this request, the knee orthosis will be considered not medically necessary at this time. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the knee orthosis (CPT code L1845).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary as you are not yet stable and as it 
would not be clinically advantageous. Transfer may be considered when treatment has completed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right arm 
(73219). 
 
You asked the Plan to pre-approve the MRI. You say that you broke your bicep tendon 3 years ago and was 
advised surgery will not work. You want to have an MRI to see if anything has changed. The Plan denied your 
request. The Plan says the requested MRI was not ordered by your provider. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file and Medicare rules. The records as well as a call to the doctor's office confirmed that the 
requested MRI was not ordered by your provider. An MRI is not one of the services that you can get without 
first getting approval from your provider. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) of the right arm (73219).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting 
on December 15, 2021. 
 You asked the Plan to pay for the self-administered drug. You say that you were not aware of the fact that your 
plan did not cover this particular drug. You also say that you should not be charged for this. The Plan denied 
your request. The Plan says the claim denied correctly. 
 
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 pay for the self-administered drug 
provided in an outpatient setting on December 15, 2021.  
 
Benefits for the self-administered drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve these services. You say that you need the inserts for your shoes. The Plan 
denied your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that your hands are tired from finger-stick testing. 
The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump and your insulin regimen does not require frequent adjustment based on testing results. 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 a continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid check provided on October 4, 2021. 
 
You asked the Plan to pay for the hearing aid check. You say that you thought hearing aid exams were covered. 
The Plan denied your request. The Plan says one hearing aid check/evaluation is covered annually with a $0.00 
copayment. The Plan also says that a hearing aid check was billed and paid for date of service March 8, 2021. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aid fitting/evaluations once every calendar year.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid check have not been met. Therefore, we decided that the Plan does not have to pay 
for the hearing aid check provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is a lack of evidence to support interspinous spacer devices 
as safe and effective as the gold standard of surgical decompression. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Current evidence 
based medical guideline and peer reviewed literature do not fully support the spinal decompression device 
procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-
reviewed outcome studies to support the use of this device for this enrollees medical condition. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
 
 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 the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip orthosis (CPT code L1686) and addition to 
lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control (CPT code L2624) 
provided on November 19, 2021. 
 
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the information provided indicates the enrollee had no problems walking within six (6) 
weeks of their injury. The Plan states a conversation with the alleged ordering provider revealed that the brace 
was not ordered by him, nor did he intend to order this brace. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that show the hip orthosis and addition to lower extremity meet 
Medicare criteria for medically reasonable and necessary. Provided records document a motor vehicle crash 
with a right femoral neck fracture and successful surgical fracture repair and good healing post-operatively; 
there is no mention of arthritis in the hip or need for a hip brace. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the hip orthosis (CPT code L1686) and addition to lower extremity, pelvic control, hip 
joint, adjustable flexion, extension, abduction control (CPT code L2624) provided on November 19, 2021.