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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure is medically necessary 
and supported by strong science. The Plan denied your request. The Plan says the clinical value has not been 
demonstrated in peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
An Intracept intraosseous basivertebral nerve ablation procedure was requested. 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 requested services. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the 
request is not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior instrumentation (22845) provided on April 12, 
2021. 
 
You asked the Plan to pay for the anterior instrumentation (22845). You say that the attached records are all 
that are available because the patient was surgical only. You say that the claim should be promptly processed. 
The Plan denied your request. The Plan says procedure code 22845 is not supported by the medical records 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22845 is anterior instrumentation; 2 to 3 vertebral 
segments (List separately in addition to code for primary procedure). 
 
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 anterior instrumentation (22845). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the operative report does not describe an instrumentation procedure. 
 
 
  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 anterior instrumentation (22845) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anterior instrumentation (22845) provided on April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter COVID-19 home testing kits provided 
on November 23, 2021. 
 
You asked the Plan to pay for the over-the-counter COVID-19 home testing kits. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the 
counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 testing kit have not been met. Specifically, the at-home COVID-19 testing 
kit was purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not have to pay 
for the over-the-counter COVID-19 home testing kits provided on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a duvalumab injection provided on 
January 5, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the provider would not accept free 
medication from the manufacturer. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy drugs.  
 
The file shows that the Plan reprocessed the claim to remove the $40 copayment for the office visit. Therefore, 
you have been asked to pay $1,459.58, which is 20% of the allowed amount for the injection ($7,297.92 
allowed amount x 20% coinsurance = $1,459.58). The injection falls within the Medicare Part B Prescription 
Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a duvalumab injection provided 
on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs this drug. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz tablets.  
 
Benefits for 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior nasal nerve ablation services. 
 
You asked the Plan to pre-approve posterior nasal nerve ablation services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says there are not enough 
published evidence to support the use of this procedure over the other available therapies. 
 
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 posterior nasal nerve ablation services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is an 81-year-old male patient who was evaluated May 2, 
2022, for chronic rhinitis, with symptoms including rhinorrhea. Based on available clinical documentation, the 
requested services for posterior nasal nerve ablation do not meet criteria for being medically reasonable and 
necessary. There is no substantive evidence that immediate radiofrequency ablation-assisted reduction of 
intranasal soft tissue to treat nasal obstruction is superior to the various other procedural techniques currently 
available. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior nasal nerve ablation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve posterior nasal nerve ablation services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Part-B injectable services provided on January 4, 2022. 
 
You asked the Plan to pay for the Part-B injectable services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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. In this case, the Plan has provided no supporting evidence to deny payment for 
these services based on Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the Part-
B injectable services provided on January 4, 2022.  
 
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 (0037U) provided on December 14, 2021. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. 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 items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93005) and specimen 
collection (C9803) provided on November 8, 2021. 
 
You asked the Plan to pay for the ECG (93005) and specimen collection (C9803). You say that the claim in 
question is payable under OPPS and the remaining balance should be paid. The Plan denied your request. The 
Plan says CPT codes C9803 and 93005 remain denied as packaged into payment for other services. 
 
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 93005 is electrocardiogram, routine ECG with at least 12 
leads; tracing only, without interpretation and report. The CPT Code Manual definition of code C9803 is 
hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-
cov-2) (coronavirus disease [covid-19]), any specimen source. 
 
We find that CPT code 93005 is not supported in the medical record. Specifically, these services are considered 
bundled with the outpatient clinic visit and not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the ECG (93005) and specimen collection (C9803) have not been met. 
Therefore, we decided that the Plan does not have to pay for the electrocardiogram (ECG) (93005) and 
specimen collection (C9803) provided on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on January 25, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the records support the procedure was 
performed by the provider and the claim denied as a duplicate in error. You say that the claim should be 
reviewed and reprocessed for reimbursement. The Plan denied your request. The Plan says a modifier was not 
billed on the claim to represent the service as separate and distinct.  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 CT scan (70450) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on August 12, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has provided no supporting evidence to deny payment for 
these services based on Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the 
anesthesia services provided on August 12, 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 office services provided on February 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office services. You say that the enrollee does not need a referral when 
participating with insurance. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 office services provided on February 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing performed on February 16, 
2022. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that you were not aware of the 
cost of the test. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for genetic testing.  
 
You have been asked to pay $720, which is 20% of the allowed amount for the genetic testing ($3,600 allowed 
amount x 20% coinsurance = $720). The genetic testing falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
genetic testing performed on February 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services provided on January 26, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has provided no supporting evidence to deny payment for 
these services based on Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the 
radiology services provided on January 26, 2022.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services as billed provided July 1, 
202, to July 19, 2020. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim paid as billed. The Plan 
denied your request. The Plan says that they have reprocessed this claim as an overpayment. 
 
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. In this case, the Plan has reprocessed this claim as an overpayment. However, 
there is no justification including why the Plan has decided to reprocess the case for overpayment.  Therefore, 
we decided that the Plan has to pay for the skilled nursing facility (SNF) services as billed provided July 1, 
202, to July 19, 2020.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from January 15, 
2022 to February 13, 2022. 
 
 You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing 
perspective; the enrollee received oral medications. The enrollee was monitored after a fall and had stable vital 
signs. The enrollee received physical, speech and occupational therapy. They were at minimal assist to contact 
guard assist level for functional mobility including gait. They required varying assist with activities of daily 
living. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided from January 15, 2022 to February 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retrograde filling (D3430), and apicoectomy (D3410) 
provided on February 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the root was calcified. You say that this 
treatment prevented a normal root canal. You also say that this service was necessary. The Plan denied your 
request. The Plan says retrograde filling is not listed as a covered service. The Plan says that apicoectomy is not 
listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the retrograde filling and apicoectomy 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the retrograde filling (D3430), and apicoectomy (D3410) provided on February 14, 2022.