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 April 21, 2022, billed with 
codes 81162, 81203, 81218, 81300, 81307, 81317, 81319, 81323, 81351, 81405, 81406, 81435, 81436, 81437 
and 81438. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 
April 21, 2022, billed with codes 81162, 81203, 81218, 81300, 81307, 81317, 81319, 81323, 81351, 81405, 
81406, 81435, 81436, 81437 and 81438.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliances coded E0673 billed for August 23, 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 claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliances coded E0673 billed for 
August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT colonography. 
 
You asked the Plan to pre-approve CT colonography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CT colonography is a nationally non-covered 
indication. 
 
The Plan must follow Medicare rules. Medicare rules say that screening computed tomographic colonography 
(CTC) is nationally non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-
approve CT colonography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223) provided on October 2, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the records show that the 
enrollee was an outpatient on the dates of service at issue. Based on this information, we decided that Medicare 
rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to 
pay for inpatient care (99223) provided on October 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test (0315U) provided August 1, 2022. 
 
You asked the Plan to pay for the DecisionDX-SCC test. You say that you are requesting the Decision Dx-SCC 
test be reprocessed at the approved Medicare established rate of $3,873.00. The Plan denied your request. The 
Plan says the documentation does not support that the services rendered were 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 DecisionDX-SCC test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the Decision 
Dx-SCC test provided on date of service August 1, 2022, at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The Decision Dx-SCC test is not supported in the 
management of squamous cell carcinoma of skin as defined by Medicare rules. 
 
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 DecisionDX-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDX-SCC test (0315U) provided August 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
October 31, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the facility is enrolled in the Medicare 
program to provide opioid treatment program (OTP) services. You also say that the program is certified by the 
Substance Abuse and Mental Health Services Administration (SAMHSA). The Plan denied your request. The 
Plan says that the claim does not meet the opioid treatment program (OTP) criteria for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
October 31, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's medical needs as they are unstable at this time. The Plan denied your request. The Plan says the 
enrollee has not had a break in skilled care since their benefit period begin. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
K0108x3). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not reimbursable. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal include a power seat elevation system, quantum back up camera, track mount, 
and display mount. These items do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108x3).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services 85025, 80053, 83036, 84439, 80061, 
83719, 84443, 82306 and 36415 provided September 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the complete medical 
records to substantiate the necessity of the service. The Plan denied your request. The Plan says the claim was 
received past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until October 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services 85025, 80053, 83036, 84439, 80061, 
83719, 84443, 82306 and 36415 provided September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 17, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 17, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408, and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 1, 2022, to 
October 14, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that home health claims require a FIPS code. 
 
We reviewed the file and the Medicare rules. We find that claim was billed with an appropriate FIPS code per 
billing criteria. Based on this information, we find that the Medicare rules for payment of the claim at issue 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from October 1, 2022, to October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services provided on May 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without 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 the monitoring services provided on May 31, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies rendered on August 21, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 wound care supplies rendered on August 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 23, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0180) provided on December 5, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the item billed. 
 
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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records do not explain the need for this item or how it would be used. 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 an orthosis (L0180) provided on 
December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve stimulator (K0108, K0109) provided on August 30, 
2022. 
 
You asked the Plan to pay for a nerve stimulator. 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 when electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pay for 
a nerve stimulator (K0108, K0109) provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 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 claims with the -GZ modifier are automatically rejected. 
 
The Plan must follow Medicare rules. The rules say that A/B MACs shall automatically deny claim line(s) 
items submitted with a GZ modifier.  
 
We looked at the file and Medicare rules. The file shows that code 81479 was billed with the -GZ modifier. 
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 rendered on October 7, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital claim for date of service September 
27, 2022. 
 
You asked the Plan to pay for the outpatient hospital claim. 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. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 61500. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. The rules also say that 
Medicare does not pay for all other services on the same day as the inpatient only procedure. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital claim for date of service September 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ondansetron tablet. 
 
You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not, as prescribed, among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Ondansetron tablet.  
 
Benefits for Ondansetron 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1686, L2624) provided on December 5, 2022. 
 
You asked the Plan to pay for the orthoses. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed services. 
 
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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records do not document the need for these items or how they would be used. 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 orthoses (L1686, 
L2624) provided on December 5, 2022.