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

 
We decided that the Plan does not have to pay for the genetic testing provided on August 30, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 
August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the determination of refractive state (92015) provided 
on November 15, 2022. 
 
You asked the Plan to pre-approve the eye refraction. You say that this should be covered. The Plan denied 
your request. The Plan says this service is not covered as part of a medical eye exam. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. In this case the eye refraction was billed as part of a medical eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the determination of refractive state 
(92015) provided on November 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 08, 2022, 
through January 09, 2022, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis code A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support primary diagnosis code of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.9-sepsis, unspecified 
organism.. 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 the inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the documentation does not consistently and completely support 
the assigned diagnosis code.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 08, 2022, through January 09, 2022, and billed with 
diagnosis code A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code B4189 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for code B4189. The Plan denied your request. The Plan says the number of units 
billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a code has an MAI of 1, appropriate use of a 
modifier may be used to report the same code on separate lines of the claim. 
 In this case, the MUE for CPT code B4189 is 1. The MAI value for this code is 1. You billed 7 units of this 
code on the same claim line, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of code B4189 have not been met. Therefore, we decided that the Plan does not have to pay for 
code B4189 billed for date of service June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99236) provided on May 1, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was 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. 
 
We find that CPT code 99236 is not supported in the medical record. Specifically, this code is included in the 
global package for codes 52344 & 52332. 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 May 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis rendered on August 31, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years. 
 
We looked at the file and Medicare rules. The file shows that the enrollee's current orthosis was not more than five years old or irreparably damaged. 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 ankle 
orthosis rendered on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 17, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should not be included 
with any other payments. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs non-ventilation for her 
end stage disease. The Plan denied your request. The Plan says the request for a home mechanical ventilator set 
in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure with severe restrictive disease from chronic obstructive pulmonary disease. The 
record indicates that the enrollee was successfully treated with BiPAP in the hospital. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has 
indicated coverage for such a device is available upon request. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair cushion billed with code E2603 for date of 
service September 2, 2022. 
 
You asked the Plan to pay for code E2603. You say that this item is covered and no authorization is required. 
The Plan denied your request. The Plan says you have failed to provide proof of delivery despite multiple 
requests for this information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain a valid proof of delivery for the item provided in this case. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the wheelchair cushion billed with code E2603 for date of service 
September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lightweight wheelchair (K0003) purchased on 
May 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for the wheelchair. You say that the electric wheelchair is necessary for 
you to have because you cannot use a regular wheelchair due to movement issues that you have. The Plan 
denied your request. The Plan says services must be received from a network provider. Services received from 
out of network providers requires prior authorization prior to receiving the care. 
 
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 reimburse you 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the lightweight 
wheelchair (K0003) purchased on May 9, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 23, 2021, 
through September 01, 2021, and billed with diagnosis code N17.0. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis N17.0 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N17.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0-Acute kidney 
failure with tubular necrosis. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis of N17.0-Acute kidney failure with tubular necrosis. Our physician reviewer found the 
member was noted to be awake and alert with no acute distress, had a creatinine of 1.6 on admission, and 
required a cardiac stent placement to the mid left anterior descending artery. The member's creatinine rose to 
1.9. The documentation stated the member's creatinine peaked to 1.9 with a baseline of 1.0, developed acute 
tubular necrosis after percutaneous coronary intervention/contrast exposure. However, there was no evidence 
of clinical symptoms or findings on physical exam consistent with a diagnosis of acute tubular necrosis. 
Therefore, diagnosis of N17.0-Acute kidney failure with tubular necrosis is not the appropriate secondary 
diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 23, 2021, through September 01, 2021, and billed with 
diagnosis code N17.0.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
October 18, 2022. 
 You asked the Plan to pay for the eye refraction. You say that Medicare covers eye refractions after cataract 
surgery. The Plan denied your request. The Plan says eye refractions are not covered as part of a medical eye 
exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. In this case the eye fraction was performed as part of a medical eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state 
(92015) provided on October 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) treatments. 
 
You asked the Plan to pre-approve the Keytruda treatments. You say that this treatment is medically necessary. 
The Plan denied your request. The Plan says the criteria for use of this drug are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda treatments. Our reviewer 
says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of cervical cancer without programmed death ligand-1 (PDL-
1) expression and unknown tumor mutational status. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied.   
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 Keytruda treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda (pembrolizumab) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for exercise equipment provided on 
December 7, 2022. 
 
You asked the Plan to reimburse you for exercise equipment. The Plan denied your request. The Plan says that 
the Plan does not cover equipment purchased to participate in online classes. Exercise equipment is not part of 
wellness allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because exercise equipment is not a covered 
benefit. Therefore, we decided that the Plan does not have to reimburse you for exercise equipment provided on 
December 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the laboratory services by a contract provider. The file does not show that the Plan provided 
notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory 
services are considered approved by the Plan. It should also be noted that the Plan made a decision based on 
medical necessity; however, did not submit medical records from the contracted provider. Therefore, we 
decided that the Plan has to pay for the laboratory services provided on June 30, 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 lab services provided on April 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that these 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 April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364), and therapeutic parental 
drugs (D9612), provided on November 17, 2022. 
 
You asked the Plan to pay for a cone beam CT capture, and therapeutic parental drugs. You say that you had to 
pay cash up front for these services. You say that you are extremely unhappy that you are not being 
reimbursed. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
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 requested items or services are not 
among those covered under this benefit. 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for a cone beam CT capture (D0364), and therapeutic 
parental drugs (D9612), provided on November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lap sleeve gastrectomy. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation in the case file is conflicting regarding at least one co-morbidity related to 
obesity. While hypertension is listed under the enrollee's past medical history, the enrollee's medication list 
does not include antihypertensive medication, and the enrollee's blood pressure has been normal on more than 
one occasion. 
 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lap sleeve gastrectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is supported by the records. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 09, 2022.