Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol biomarkers; 1 or 2 (CPT code 80321) provided on 
March 15, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 services have not been met. Procedure code 80321 denied as a 
non-allowed item or service for OPPS, as determined in the I/OCE CMS Specifications manual and depicted on 
Addendum B with status indicator B. Services with a status indicator of B always return OCE edit 62 and are 
returned to the provider. The remaining lines processed per OCE with reason 0992  please correct OCE edit 
error on other claim line. Therefore, per the above guidelines, we find the Medicare rule for reimbursement of 
this March 15, 2022, claim has not been met. Therefore, we decided that the Plan does not have to pay for 
alcohol biomarkers; 1 or 2 (CPT code 80321) provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power operated vehicle (POV). 
 
You asked the Plan to pre-approve a group 2 POV. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs (K0806, K0807, K0808) have 
added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per L33789, the requested group 2 POV is not medically reasonable 
and necessary, and therefore is not a covered benefit. Based on this information, we decided that Medicare 
rules for coverage of a group 2 POV. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 2 power operated vehicle (POV).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Tempus tumor origin testing (81479) billed for date of service 
November 23, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. The specimen in this case was collected on July 6, 2021, rather than the billed date of 
service November 23, 2021. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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 addressed nor acknowledged the exceptions to the 
applied rule. The testing in this case was performed on a solid tumor sample which was collected as part of a 
surgical procedure in a hospital setting. It is very likely that an exception has been met in this case, which 
means that the correct date of service would be the date the testing was performed. Therefore, we decided that 
the Plan has to pay for Tempus tumor origin testing (81479) billed for date of service November 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the level of services. The 
Plan denied your request. The Plan says the code 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time. 
 We find that CPT code 99152 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the sedation services billed for date of service March 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on January 22, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says a valid claim was not filed until after the timely filing deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency room services was not filed until June 15, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for emergency room services provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biopsy of vaginal mucosa to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a biopsy of vaginal mucosa. You say that the member should have 
continued care as she is established with you. You also say that you only have surgical services at this facility. 
 The Plan denied your request. The Plan says the requested provider/facility is out-of-network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 biopsy of vaginal mucosa. Our reviewer says that the service does not 
establish the medical necessity and reasonableness, as defined by Medicare rules. Our physician reviewer 
found the record provided does not document that the requested procedure is emergently or urgently needed, or 
that the enrollee is outside of the network area. Our physician reviewer also found that the record does not 
indicate that the enrollee is receiving active ongoing care that has a need to continue with the requested 
physician. 
 
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 biopsy of vaginal mucosa have not been met.  
 
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 a biopsy of vaginal mucosa. Therefore, we decided that 
the Plan does not have to pre-approve a biopsy of vaginal mucosa to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 6, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 12001 is bundled into payment for code 26750.  
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 12001 
is a column II code to column I code 26750. 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 12001 billed for date of service March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81455) provided on May 2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the date of service for a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was 
collected. The specimen was collected on April 13, 2022, rather than the billed date of service May 2, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that generally laboratory services should be reported 
with the date of specimen collection as the date of service; however, there are three exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the records show that the specimen in this case 
was a blood sample which was collected on April 13, 2022. It is not clear that the specimen was collected in a 
hospital setting and that it was medically necessary for the sample to have been collected only in a hospital 
setting. An exception to the general rule has not been met in this case. Therefore, we decided that the Plan does 
not have to pay for laboratory testing (81455) provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was a routine visit to renew blood pressure 
medicine. You also say that your primary physician was not available for patients, but the office personnel said 
that they bill as a practice not by physician. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that these services were not approved in advance. 
 
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 June 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76856 billed for date of service December 6, 
2021. 
 
You asked the Plan to pay for procedure code 76856. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 76856 is bundled into payment for code 93979.  
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 76856 
is a column II code to column I code 93979. 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 76856 billed for date of service December 6, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the cervical spine (72125). 
 
You asked the Plan to pre-approve a CT of the cervical spine. The Plan denied your request. The Plan says that 
this request does not meet criteria for medical necessity. 
 
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 CT of the cervical spine. Our 
reviewer says that a CT of the cervical spine is reasonable. Our physician reviewer found you have had a 
thorough workup and treatment to date but still have significant pain. Our reviewer also found that while a 
magnetic resonance imaging may show an element of degenerative facet arthrosis, the requested CT may show 
the level of maximum degenerative change, thus providing a target for direct injection of steroids into the most 
severely affected joint. 
 
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 CT of the cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve a computed tomography (CT) of the cervical spine (72125).  
 
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 the genetic testing provided on May 10, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that the enrollee's physician ordered genetic 
testing for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your 
request. The Plan says the service does not meet Medicare criteria. 
 
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 
May 10, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99236) provided on June 7, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is 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. 
 
In this case, the CPT Code Manual definition of code 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date. 
 
We find that CPT code 99236 is not supported in the medical record. Specifically, this service is included in 
code 99220 that was billed for the previous date of service. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99236) provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2311, 
E2313, E2377, E1007). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that your legs and arms are 
really weak. You cannot walk and the wheelchair that you were offered was to expensive. The Plan denied 
your request. The Plan says you do not have a medical need for multiple power options included with the group 
3 power wheelchair. An electronic connection, an expandable controller and an expandable controller harness 
cannot be covered as it is not medically necessary to control the three requested power options through the 
joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a group 3 power 
wheelchair can be covered if the medical necessity for a PWC is met and if the disorder causing the mobility 
limitation is a neurological condition, myopathy or congenital skeletal deformity. You must also require a drive 
control interface, power tilt or a power recline seating system and if there has been a specialty evaluation that 
was performed by a licensed/certified medical professional, such as a physical or occupational therapist. An 
expandable controller is an electronic system that is capable of accommodating one or more additional features 
and can operate 3 or more powered seating options. In this case, you have a neurologic disorder with functional 
deficits. Criteria for a power wheelchair are met. The documentation does not indicate that you have any 
pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or 
recline. 
The requested electrical accessories would not be medically necessary as you do have use of the upper 
extremity and can operate and could control the power options using the switches that are included in the basic 
wheelchair. Although criteria for a PWC are made, the documentation doesn't support the medical necessity for 
the requested group 3 PWC with accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2311, E2313, E2377, 
E1007).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you want the supporting records you are appealing 
with reviewed and reprocessed. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that these services were not approved in advance. 
 
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 May 5, 2022, by an 
out-of-network (OON) provider.