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

 
We decided that the Plan does not have to pre-approve Jakafi. 
 
You asked the Plan to pre-approve Jakafi. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Jakafi.  
 
Benefits for Jakafi 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213, 99214) provided from January 25, 
2022, to February 9, 2022, by the out-of-network (OON) providers. 
 
You asked the Plan to pay for the evaluation and management services. You say that the services should be 
covered. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan also says 
that the services you received were not urgent or emergent in nature. 
 
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 providers in this case are not network providers with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visits (99213, 99214) provided from January 25, 2022, to February 9, 
2022, by the out-of-network (OON) providers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prescription drug, Fluorouracil. 
 
You asked the Plan to pre-approve a prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested medication does not fall under Part B coverage. The enrollee 
does not have pharmacy (drug) benefits administered by the Plan. 
 
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 a prescription drug, 
Fluorouracil.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 88341, 88342, and 88365. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88341, 
88342, and 88365 is a column II code to column I code 88360. 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.  
 
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 88364 is in situ hybridization (eg, FISH), per specimen; 
each additional single probe stain procedure (list separately in addition to code for primary procedure). 
 
We find that CPT code 88364 is not supported in the medical record. Specifically, the add-on code was not 
billed with a required primary procedure code. 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 laboratory services billed for date of service 
February 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97535, 97166) provided on 
July 7, 2022. 
 
You asked the Plan to pay for the occupational therapy services. You say that the services were medically 
necesary. The Plan denied your request. The Plan says the claim was not billed with a correct diagnosis code. 
 
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 97535, & 97166 is not supported in the medical record. Specifically, the billed 
diagnosis code (H35.3211, H35.3221) does not reflect the correct laterality. There is a more appropriate 
(bilateral) diagnosis code for this service. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for occupational therapy services (97535, 97166) provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Specimen collection for severe acute respiratory syndrome 
coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source (G2023) provided May 13, 
2022. 
 You asked the Plan to pay for the laboratory service. You say that this was a COVID-19 test which should have 
$0 cost-share. Your wife had the same test and the Plan paid the $21.09 cost. The Plan denied your request. 
The Plan says services not covered under foreign benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. COVID-19 testing for non-diagnostic testing for 
screening purposes is not covered by Medicare. Plans and issuers are not required to provide coverage of 
testing such as for public health surveillance or employment purposes. Therefore, we decided that the Plan does 
not have to pay for Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) 
(coronavirus disease [covid-19]), any specimen source (G2023) provided May 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93970) provided on February 1, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that the service was medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided to support the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the duplex scan have been met. 
Insufficient records were provided to determine if the services were emergent or how the enrollee presented to the out-of-network provider. Therefore, we decided that the Plan does not have to pay for a duplex scan 
(93970) provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on January 4, 2022. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was medically necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says the enrollee 
previously had this same test for the same cancer diagnosis on September 23, 2021. The repeat testing in 
question was 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 pay for Guardant360 testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that this same test was performed on September 23, 2021, for the same cancer 
diagnosis. The records do not support that repeat testing was medically necessary in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant360 testing provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on May 1, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was billed the 
day prior to the major surgical procedure 33208 (insertion of new or replacement of permanent pacemaker with 
transvenous electrode(s); atrial and ventricular). This means payment for this service is included in the payment 
for the surgical procedure. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay 
for the subsequent hospital care services coded 99232 provided on May 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on March 17, 
2022. 
 
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously 
paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 21, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the X-ray exam of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided 
on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics/inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you need this orthotic to prevent your foot from 
returning to its prior state. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics/inserts (L3000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you completed the claim form correctly. 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 August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 procedure code 70450 billed for date of service June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022, to July 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022, to July 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on February 22, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for radiology services 
provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
May 31, 2022. 
 You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the services 
rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the targeted genomic sequence analysis panel is 
covered when the enrollee has stage three or four non-small cell lung cancer.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has stage one cancer. 
Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence 
analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted 
genomic sequence analysis panel provided on May 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services you received from a Marriage and Family 
Therapist (MFT) on May 31, 2022. 
 
You asked the Plan to pay for the MFT services. You say that telehealth services should be covered 100%. The 
Plan denied your request. The Plan says you used an ineligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider you saw is a 
MFT, which is not a valid Medicare provider type.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MFT services have not been met. Therefore, we decided that the Plan does not have to pay for 
telehealth services you received from a Marriage and Family Therapist (MFT) on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 June 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 27265. 
 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 93042 
is a column II code to column I code 27265. 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 93042 billed for date of service March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services (80053, 83735, 85025) to be 
provided by a laboratory provider other than the site designated by your primary care physician. 
 
You asked the Plan to pre-approve laboratory services. You say that it would be easier for you to get laboratory 
services at the requested provider. The Plan denied your request. The Plan says rules for coverage for 
laboratory services have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees must use their primary care provider's designated site in order to receive in-network 
coverage for laboratory services. 
 
The requested provider in this case is not your primary care physician's designated site. Therefore, we decided 
that the Plan does not have to pre-approve laboratory services (80053, 83735, 85025) to be provided by a 
laboratory provider other than the site designated by your primary care physician.