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

 
We decided that the Plan has to pay for the BRCA1, BRCA2 gene analysis; full sequence analysis and full 
duplication/deletion analysis provided on April 20, 2022. 
 
You asked the Plan to pay for the BRCA1/BRCA2 genetic testing. 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 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare will cover BRCA testing for individuals with a personal 
history of prostate cancer (Gleason score greater than or equal to 7) at any age with greater than or equal to 2 
first-, second-, or third-degree relatives with breast cancer. The rules also say Medicare will cover BRCA 
testing for individuals with limited family history/structure, defined as fewer than 2 females first- or second-
degree relatives having lived beyond age 45 in either lineage. In this case, the records show that the enrollee 
has a personal history of prostate cancer with a Gleason score of 7 and a limited family history/structure with 
the enrollees mother having been adopted and having a personal history of breast cancer. Based on this 
information, we decided that Medicare rules for coverage of the BRCA genetic testing have been met. 
Therefore, we decided that the Plan has to pay for the BRCA1, BRCA2 gene analysis; full sequence analysis 
and full duplication/deletion analysis provided on April 20, 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 pay for an office visit service for an infectious agent detection by 
nucleic acid (DNA or RNA); influenza virus (87502) provided on May 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an office visit service. You say that you disagree with the denial of payment and 
are requesting reconsideration of payment on the claim. The Plan denied your request. The Plan says enrollees 
must receive care from network providers. 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. 
 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 service for an infectious agent 
detection by nucleic acid (DNA or RNA); influenza virus (87502) provided on May 16, 2022, by an out-of-
network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva 120 MG/1.7 ML 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the Plans required drug(s) likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xgeva 120 MG/1.7 ML
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the occupational therapy services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as the requested provider does not have the proper credentials and they can be provided in-network by 
qualified providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
occupational therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (procedure code 93970) provided to the 
enrollee on October 19, 2021. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the diagnosis is inappropriately coded. 
 
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 93970 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study." 
 
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 scan. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the medical records do not support the 
use of procedure code 93970. There are no medical records available. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a duplex scan (procedure code 93970) provided to the enrollee on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve paravertebral facet joint injections. You say that the enrollee has back pain 
and that the requested injection services are medically necessary. The Plan denied your request. The Plan says 
the requested injection services are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that paravertebral facet joint injections are covered when 
medically reasonable and necessary for certain medical 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 paravertebral facet joint injections. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
lumbar back pain and is requesting bilateral L4/5 and L5/S1 medical branch block (MBB) Facet injections. 
Lumbar facet blockade techniques are used in the diagnosis and treatment of chronic lower back pain. Previous 
injections include a lumbar medical branch block (LMBB) on August 26, 2021, and a bilateral L4-S1 with 80% 
relief as well as a LMBB on April 13, 2022, with 75% relief. The diagnostic blocks did not achieve 80% relief 
on both sets of MBBs, and therefore the request is not considered medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of paravertebral facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve paravertebral facet joint injections.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT, heart, with contrast material, for evaluation of cardiac 
structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation 
of venous structures, if performed) (CPT code 75572). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the CT scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our physician reviewer 
found the requested CT of the heart is necessary as part of the workup prior to the planned left atrial ablation 
procedure and will also allow evaluation of the pulmonary veins which is necessary when this procedure is to 
be done. The request is reasonable and necessary for the upcoming left atrial ablation. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D 
image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) (CPT 
code 75572).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym membership purchased between January 1, 2022, to 
April 30, 2022. 
 
You asked the Plan to pay for the gym membership. You say that you believe you should be reimbursed for the 
gym membership. The Plan denied your request. The Plan says you have exceeded the limits set in the 
subscriber agreement. 
 
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 Plan covers qualifying 
fitness expenses up to $50 per month, or fitness equipment. 
 
The Plans rules for coverage of gym benefits have not been met because the record shows that you purchased 
both a gym membership and fitness equipment. You are only able to be reimbursed for one or the other of these 
services/items. Therefore, we decided that the Plan does not have to pay for the gym membership purchased 
between January 1, 2022, to April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) extracellular fluid 
analysis for lymphedema assessment (93702). 
 
You asked the Plan to pre-approve the diagnostic service. You say that the requested service helps to identify 
the onset of lymphedema in an arm or leg before noticeable swelling occurs. The Plan denied your request. The 
Plan says the requested service 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 diagnostic service. Our reviewer 
says that the requested diagnostic services is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee appears to already have 
some degree of lymphedema. The reviewer found that screening for lymphedema now that she is already using 
a sleeve is not going to lead to a better outcome in this case as any therapies for lymphedema can be considered 
now without the results of the screening test. Therefore, this request for bioimpedance spectroscopy (BIS) 
extracellular fluid analysis for lymphedema assessment will be considered 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 diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bioimpedance spectroscopy (BIS) extracellular fluid analysis for lymphedema 
assessment (93702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic cardiology panel provided on October 25, 2021, 
billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81413, 81414 and 81442. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this genetic testing is not 
covered by Medicare, and this panel was not billed in accordance with Medicare rules. 
 
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 cardiology panel provided on October 25, 2021, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 
81411, 81413, 81414 and 81442.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the neurology services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
non-emergent and can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neurology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment for the urgently needed services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $40 
copayment for urgently needed services.  
 
 
  You have been asked to pay a $40 copayment for the urgently needed services. 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 urgently needed services provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SBRT (CPT code 77373). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your records do not show cancer in a site that meets the National Comprehensive Cancer 
Network (NCCN) guidelines for treatment with SBRT. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT is not within accepted standards or medical care. 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 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve the SBRT (CPT 
code 77373).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
May 17, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with having a cost share because you did not have one under your previous plan. The Plan denied your request. 
The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for Medicare covered durable medical equipment and related supplies.  
 
You have been asked to pay $80.93, which is 20% of the total allowed amount for durable medical equipment 
($404.66 allowed x 20% = $80.93). Durable medical equipment 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 durable 
medical equipment provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service April 25, 
2022, and procedure code 99239 billed for date of service April 28, 2022. 
 
You asked the Plan to pay for codes 99223 and 99239. You say that the records meet the billed level of service. 
The Plan denied your request. The Plan says the medical records do not support code 99223 for date of service 
April 25, 2022 (the other dates of service have been paid). Instead, code 99222 should have been billed for this 
date of service. The medical records also do not support the billing of code 99239 for date of service April 28, 
2022. Instead, the records supported 99238. 
 
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, which requires these three key components: a comprehensive history, a 
comprehensive exam, and medical decision making of high complexity.  The definition of code 99239 is 
Hospital Discharge Day Management Services; more than 30 minutes.  
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 codes 99223 and 99239. Our reviewer says that codes 99223 
and 99239 are not supported in the medical record. Our reviewer found in relation to code 99223, for initial 
hospital care 3 of 3 key components must be met or exceeded, in this case documentation supports: History: 
Expanded problem focused; Exam: Expanded problem focused, and medical decision making of moderate 
complexity. The documentation does not support 3 of 3 key components for level CPT 99223 Comprehensive 
history; Comprehensive exam and medical decision making of high complexity.  Therefore CPT 99223 cannot 
be verified for this date of service. In relation to code 99239, hospital discharge day service is a time procedure 
code. The medical record does not include documentation of time spent more than 30 minutes.  Therefore, this 
procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99223 and 99239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service April 25, 2022, and procedure code 
99239 billed for date of service April 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) 
provided on April 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $200 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $200 copayment for the ambulance transportation services. 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 ambulance transportation services (A0427) provided on April 29, 
2022.