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

 
We decided that the Plan does not have to pre-approve laboratory services provided to the enrollee on 
September 24, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this test is unlikely to impact therapeutic decision-making in the clinical management of 
the patient and will be denied automatically as not medically necessary and screening testing. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the available documentation does not support that the FoundationOne Heme laboratory services on 
9/24/21 was medically reasonable and necessary for the enrollee. The documentation does not support the 
decision impact of the testing 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laboratory services provided to the enrollee on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardigram report (93010) provided on September 
22, 2021. 
 
You asked the Plan to pay for the electrocardiogram report. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 93010 
and 31500. 
 
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 93010 
is a column II code to column I code 31500. 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 the electrocardigram report (93010) provided on September 22, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 4 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided as of April 21, 2022, there is no documentation that further skilled nursing services 
are required to effectively provide treatment, care, and/or services in order to improve your condition, or to 
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. No medical notes 
from your treating physician are provided documenting an order or need for additional skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) and the home visit for the 
evaluation and management of a new patient (99343) rendered by the out-of-network (OON) provider on 
November 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider in this case is not a network provider 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 services 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 nail debridement (11721) and the home visit for the evaluation and 
management of a new patient (99343) rendered by the out-of-network (OON) provider on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-stage Renal Disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. Payment for these services is included in the ESRD payment. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided July 
6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided to the enrollee from November 2, 
2020, to November 6, 2020. 
 
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 CPT 99443 is not appropriate to bill for inpatient services. 
 
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 99443 is "Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion." 
 
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 in this case, visits were consultations while enrollee was inpatient status. Therefore, 
there is a more appropriate code set to report for services provided  Interprofessional 
Telephone/Internet/Electronic Health Record Consultations CPT codes 99446, 99447, 99448, 99449, 99445.   
 
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 inpatient services provided to the enrollee from November 2, 2020, to November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic-crown (D6245) provided by a participating provider 
on October 20, 2021. 
 
You asked the Plan to pay for a pontic-crown. You say that you do not agree with this denial. The Plan denied 
your request. The Plan says the maximum dental allowance benefit has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic-
crown when the services are medically necessary and reasonable. 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a pontic-crown have already been met. Therefore, we decided that the Plan does not have to pay 
for a pontic-crown (D6245) provided by a participating provider on October 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads, 
interpretation and report only (93010) provided June 21, 2021. 
 
 
 You asked the Plan to pay for the electrocardiogram. You say that please review the attached medical records 
for the billed EKG that was denied for hospice related. The diagnosis R06.02 was not related to the enrollee's 
hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the members terminal condition. 
 
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 electrocardiogram, routine ECG with at least 12-leads, 
interpretation and report only (93010) provided June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on December 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on  
December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a phlebotomy (99195) provided on August 
24, 2021. 
 
You asked the Plan to waive the copayment for the phlebotomy. 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 $295 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
 You have been asked to pay a $106.86 copayment for a phlebotomy, which is less than the standard $295. 
Phlebotomys fall within the Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for a phlebotomy (99195) provided on August 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 
10, 2021. 
 
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 procedure code 99284 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99284 (Level 4 ER visit) and 99285 (Level 5 ER visit). 
Code 99284 is a column II code with a modifier indicator of 1 when billed with column I code 99285. Code 
99284 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the emergency room (ER) services rendered on September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the complete bilateral noninvasive 
physiologic studies of upper or lower extremity arteries (93923) provided on November 23, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 You have been asked to pay $136.05 for the Medicare-covered radiological diagnostic service provided. This is 
the Plans allowed amount for this service which is less than the applicable 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 the complete bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (93923) provided on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging of the 
brain (70554) provided on December 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
 You have been asked to pay $277.28 for the Medicare-covered diagnostic radiology service provided. This is 
the Plans allowed amount for this service which is less than the applicable 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 the magnetic resonance imaging of the brain (70554) provided on 
December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a short-latency somatosensory evoked potential study (SSEP) 
(95927) provided to the enrollee on May 24, 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 denied code remains not supported. 
 
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 92927 is "Short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the 
trunk or head." 
 
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 the records provided for review did 
not indicate that SSEPs were performed of the trunk and/or head. Rather, there were only upper and lower 
extremity SSEPs performed (CPT 95938).  The technical report also did not even indicate use of the CPT code under review (95927). In as much it can be 
concluded that the records do not support use of the code under review. 
 
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 a short-latency somatosensory evoked potential study (SSEP) (95927) provided to the enrollee 
on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bandage supplies (A4452, A6445, A6446, A6449) provided 
on October 6, 2021. 
 
You asked the Plan to pay for bandage supplies. You say that the items at issue are a medical necessity for you. 
The Plan denied your request. The Plan says rules for payment 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. 
 
 
 
 
 
 
 
 
 
 Codes A4452, A6445, A6446, and A6449 have a status indicator of X on the Physician Fee Schedule. This 
means that they are a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of bandage supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
bandage supplies (A4452, A6445, A6446, A6449) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic testing provided to the 
enrollee on September 26, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the diagnosis code does not substantiate this service. 
 
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 the clinical documentation in the case file does not support that the cardiac risk assessment genetic 
testing provided on 9/26/2021 was medically reasonable and necessary for the enrollee in this case.  
 
 The documentation does not support that the testing was furnished in accordance with accepted standards of 
medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a 
malformed body member, and that it was at least as beneficial as an existing and available medically 
appropriate alternative. It appears that the Medical Professional Signature on the Cardio Genomic Test 
Requisition does not match the Ordering Physician on the Hereditary Genetic Cardiac Test results. 
 
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 does not have 
to pay for cardiac risk assessment genetic testing provided to the enrollee on September 26, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology (prostate) gene expression profile by real-time RT-PCR 
of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score (CPT code 0005U). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that there is not enough evidence to support the ExoDx prostate test 
currently. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this urine exosome gene expression assay is a noninvasive, urinary 3-gene expression assay that 
discriminates high-grade (GS7) from low-grade (GS6) cancer and benign disease. In this study, the urine 
exosome gene expression assay was associated with improved identification of patients with higher-grade 
prostate cancer among men with elevated PSA levels and could reduce the total number of unnecessary 
biopsies. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and 
SPDEF), urine, algorithm reported as risk score (CPT code 0005U).  
 
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.