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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that IRF 
care is reasonable and medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on May 5, 2022 with an embolic stroke during cardiac surgery. She was medically stable as of May 12, 
2022 per cardiology. The enrollee needs physical, occupational, and speech therapy in an IRF and is not safe to 
be in a lower intensity setting, such as a skilled nursing facility, due to recent ventricular tachycardia and 
cardiomyopathy. The complexity of the enrollee's, medical and rehabilitation needs require an acute hospital 
inpatient rehab stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound scan of extremity veins (93970) provided on 
May 31, 2021. 
 
You asked the Plan to pay for an ultrasound scan of extremity veins. You say that the service at issue was a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ultrasound scan of extremity veins have not been met. Specifically, the Plan has documented 
that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided 
that the Plan does not have to pay for an ultrasound scan of extremity veins (93970) provided on May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services (99214, 92083, 92134) provided on 
December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that you do not understand why these services are 
denied and you need a referral. The Plan denied your request. The Plan says out-of-network care is only 
covered in certain limited circumstances. The provider in this case is out-of-network, and the services were not 
urgent, emergent, or pre-approved. There were in-network providers who could have provided these services. 
 
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 vision care services (99214, 92083, 92134) 
provided on December 3, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test (81479) provided on November 
8, 2021. 
 
You asked the Plan to pay for GeneSight psychotropic test. You say that you request reconsideration of the 
original determination and cover the GeneSight Psychotropic test as medically necessary. The Plan denied your 
request. The Plan says GeneSight Psychotropic has not been shown to be useful therefore, is not considered 
medically necessary and appropriate. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of GeneSight psychotropic test have not been met. Therefore, we decided that the Plan does not have 
to pay for GeneSight psychotropic test (81479) provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cancer panel coded as 81292, 81321, 
81295, 81479, 81201, 81317, 81408, 81406, 81403, 81407, 81404, 81405, 81162, 81298 provided June 21, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached all supporting documents 
along with a detailed letter of medical necessity. Kindly review this case and consider this claim for payment. 
The Plan denied your request. The Plan says the service do not meet Medicare NCD/LCD criteria. This service 
was included under a more appropriate procedure code on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
We find that CPT codes are not supported in the medical record. Specifically, the claim submitted was found to 
include multiple genes billed individually, using T1 andT2 codes, which were all part of a genomic sequencing 
panel.  per the Centers for Medicare and Medicaid Services National Correct Coding Initiative Coding Policy 
Manual, if one laboratory procedure evaluates multiple genes using a next generation sequencing 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 CPT code. 
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 comprehensive cancer panel coded as 81292, 81321, 81295, 81479, 81201, 81317, 81408, 81406, 
81403, 81407, 81404, 81405, 81162, 81298 provided June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve imaging services. You say that it is medically necessary for the services to 
be done at an OON facility. The Plan denied your request. The Plan says there are locations in-network where 
the services can be performed. 
 
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 
imaging services 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 laboratory testing provided on November 25, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are legally obligated to process specimens and must 
provide service without prejudice. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed 
on this claim. 
 
 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 lab tests 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 laboratory testing provided on November 25, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT codes 99285 and 93010. We decided that the Plan does not have 
to pay for CPT code 99053.  
 
You asked the Plan to pay for CPT codes 99053, 99285 and 93010. The Plan says that CPT code 99053 is 
denied as bundled services are not eligible for separate payment. 
 
We decided that the Plan has to pay for CPT codes 99285 and 93010.  
 
The Plan says that you are only appealing CPT code 99053. The records submitted do not support this is the 
only code being requested. The Plan has not forwarded any evidence to support the other codes are not being 
requested or that they are being handled separately. It is the burden of the Health Plan to substantiate their 
decision with evidence. In this case, the decision to not review CPT codes 99285 and 93010 has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for CPT codes 
99285 and 93010.  
 
We also decided that the Plan does not have to pay for CPT code 99053. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of CPT code 99053 have not been met Therefore, we decided that the Plan does not have to pay for CPT code 
99053. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 27, 2021 to May 28, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the enial. The Plan denied your 
request. The Plan says the device intensive procedure was billed without a device code. 
 
The Plan must follow Medicare rules. The rules say that providers must report procedure codes that require the 
use of devices must also report the applicable HCPCS codes and charges for all devices that are used to 
perform the procedures 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required device 
procedure codes. 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 pay for the surgical services rendered on 
May 27, 2021 to May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect test (0012M) provided on June 3, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CxBladder Detect test. You say that you believe the combination of the 
medical records and strong peer reviewed publications along with the support of Novitas/CMS LCD coverage 
is sufficient evidence to rule in your favor and provide payment for this claim. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 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 the CxBladder Detect test (0012M) provided on 
June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on July 20, 2021. 
 
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 this should be reported with CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that 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 the computed tomography (CT) scan of the head/brain rendered 
on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotropic test (81479) provided November 
10, 2021. 
 
 
 You asked the Plan to pay for the GeneSight psychotropic test. You say that you request reconsideration of the 
original determination and cover the GeneSight Psychotropic test as medically necessary. The Plan denied your 
request. The Plan says GeneSight psychotropic has not been shown to be useful and is therefore considered not 
medically necessary and appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneSight psychotropic test have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight psychotropic test (81479) provided November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 21, 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. 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 these 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 rendered on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 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. 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 these 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 rendered on January 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 13, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 the computed tomography (CT) scan of the head/brain rendered 
on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22612, 22614), laminectomy, facetectomy 
or foraminotomy (63052, 63053), posterior non-segmental instrumentation (22840) and allograft (20930). 
 
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 these services are experimental/investigational. 
 
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. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for your pathology, including the relatively severe spinal stenosis at the planned BacFuse levels. 
There is no discussion of spinal instability on flexion/extension films, and no discussion indicating that a 
DEXA scan has demonstrated the lack of significant osteoporosis in you. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Our physician reviewer found that your 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 arthrodesis (22612, 22614), laminectomy, facetectomy or foraminotomy (63052, 63053), 
posterior non-segmental instrumentation (22840) and allograft (20930).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from May 5, 2021, to May 10, 
2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services should be covered. You also say that 
you cannot afford to pay this bill. The Plan denied your request. The Plan says that the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan has not provided evidence that the bill for $9,339.72 is 
getting corrected. Therefore, the plan cannot charge the enrollee any more than the $100 cost share that was 
promised. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from May 5, 
2021, to May 10, 2021. The $100 cost share amount still applies. 
 
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.