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

 
We decided that the Plan does not have to pay for an office visit and surgery provided from March 4, 2022, to 
March 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and surgery performed in an out-of-network physician's office. 
You say that you are requesting reconsideration for the cost share applied. You say the services received were 
for an emergency surgery for possible cancer cells while in Florida. The Plan denied your request. The Plan 
says the services were performed by an out-of-network provider without obtaining a prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit and surgery provided from March 4, 
2022, to March 25, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Heme testing provided on January 7, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that FoundationOne Heme is a comprehensive genomic profiling (CGP) test combining DNA and RNA 
sequencing for patients with hematologic malignancies, sarcomas or solid tumors where RNA sequencing is 
desired. The documentation indicates: This is for patients who had Targeted genomic sequence analysis panel, 
solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater 
genes, interrogation for sequence variants and copy number variants or rearrangements, if performed for 
patients with dx of Chronic myeloproliferative disease. The review indicates that the the requested testing at 
issue in this case was medically reasonable and 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 testing have not been met. Therefore, we decided that the Plan has to pay for 
the FoundationOne Heme testing provided on January 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care and urology office visits 
provided from January 26, 2022, to February 17, 2022. 
 
You asked the Plan to waive the copayment for urgent care and urology office visits. You say that these 
services were needed due to complications following a colonoscopy. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 $35 
copayment for specialist office visits. The Plan contract also says that you must pay a $40 copayment for 
urgently needed services. 
 
You have been asked to pay a $35 copayment for each urgent care and urology office visit. A urologist is considered a specialist. While the urgent care visit falls under the urgently needed services benefit category, the 
Plan has chosen to honor the original processing with a $35 copayment. 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 copayment for urgent care and urology office visits provided from January 26, 2022, to February 17, 2022.  
 
Your complaint about the relationship of these services to your colonoscopy is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health skilled nursing services. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
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. While the case file states that records were received from the contracted home 
health agency, and a letter specifically references home health records from 10/12/2022, no records have been 
provided to the for review. Without this information, the plan's denial is not able to be substantiated. Therefore, 
we decided that the Plan has to pre-approve home health skilled nursing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the osteogenesis stimulator (E0748) 
provided November 29, 2021. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that to your 
understanding, the medical cost should have been fully covered, except for the co-payment unless it is 
otherwise specified. You believe you are not responsible for the payment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 10% 
coinsurance for all other Medicare covered DME for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $317.03 ($3,170.33 x 10%) for the Osteogenesis stimulator. This item/service falls 
within the Durable medical equipment (DME) and related 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 the osteogenesis stimulator (E0748) provided November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the systolic and diastolic congestive heart failure. The 
record indicates that the enrollee underwent a transthoracic echocardiogram in September 2022. The provided 
record indicates that the enrollee is stable and requests the repeat study at a future date. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 14, 
2021, to April 23, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that this is the correct code for the medically 
necessary services provided. 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 April 14, 2021, to April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (L8702) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a partial hand prosthesis with individually powered digits is considered experimental 
and 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the requested device is used for the upper extremity. It is an arm brace that is motorized 
and is intended to help an individual with upper extremity weakness to move their arm and hand. The requested 
device has not been shown to be superior to other standard treatments for the medical condition. The studies do 
not indicate the MyoPro brace improves an individuals function or general health. The requested device is not 
medically 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered upper extremity range of motion assist device (L8702) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement (procedure code 36228) 
provided to the enrollee on November 23, 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 the records do not support the services billed. 
 
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 36228 is "Selective catheter placement, each intracranial 
branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation 
and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior 
cerebellar artery) (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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that at issue is the accuracy of the 
submitted coding for the angiographic procedures performed. The report is reviewed, and coding appears accurate for each entry except 36228-RT. The documentation does not support coding for 36228-RT. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement (procedure code 36228) provided to the enrollee on November 23, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 1, 2021 billed 
with codes 81401, 81227, 81225, & 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says a single panel cannot be billed as multiple unbundled codes. 
 
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 
September 1, 2021 billed with codes 81401, 81227, 81225, & 81226.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the appropriate modifier. 
 
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 payment for CPT code 94726 is not supported in the medical record. Specifically, code 94726 is 
assigned a PC/TC indicator of 1. As such, the professional component must be billed with modifier -26 for 
payment to be considered. 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 the services provided 
on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 31, 2021 to 
November 8, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of secondary diagnosis code J15.6. 
 
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 J15.6. 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 submitted records do not support the billing of secondary diagnosis code J15.6. Our 
physician reviewer found the enrollee presented to the hospital with constant talking after a fall. The 
emergency department exam documented no acute distress, normal pulmonary effort, and mental status as alert 
and oriented to person, place, and time. A chest x-ray revealed mild vascular congestion and interstitial edema, 
left basilar consolidation worrisome for pneumonia. While it is acknowledged that the physician documented 
the diagnosis of gram-negative pneumonia, this diagnosis is not sufficiently supported by the medical record 
documentation. While the chest x-ray supported the diagnosis of pneumonia, there was no culture to support 
gram-negative bacteria.  
 
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 October 31, 2021 to November 8, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve a percutaneous vertebroplasty. You say that the enrollee is in significant 
pain and the records provided support the need for the requested service. The Plan denied your request. The 
Plan says the requested procedure is not medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation is covered for 
certain clinical indications. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation that the fracture is less than 12 weeks old on imaging studies. 
 
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 percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebroplasty.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee is not part of an FDA approved study. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 18, 2017, the Centers for 
Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence 
Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia provided on March 25, 2022. 
 
You asked the Plan to pay for the anesthesia. You say that the medical records prove the services were 
medically necessary. You say that the claim should be reviewed and reconsidered for payment. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia provided on March 25, 2022.