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

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (CPT code 99283) provided to the enrollee on June 4, 2021. 
 
You asked the Plan to pay for the service. You say that the claim was billed with the appropriate diagnosis code 
that can be payable as per guidelines. The Plan denied your request. The Plan says the services are not 
appropriate for the diagnosis 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. 
 
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 service. Our reviewer found the review has determined 
that the services were not appropriate for the diagnosis billed. Specifically, there was no medical decision 
making of moderate complexity. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99283) 
provided to the enrollee on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99205) provided to the enrollee on 
June 14, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network office services. You say that the enrollee had notified the 
Plan of the change of residence but the update to the Plan did not occur. The Plan denied your request. The 
Plan says there is no record of a requested demographic change on file from the enrollee prior to date of 
service. 
 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. 
 
There is no record of a requested demographic change is on file from the enrollee prior to date of services. As 
services are not of an emergency nature, and there was no primary care physician (PCP) referral; the claim has 
correctly processed as out-of-network. 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 office 
visit (CPT code 99205) provided to the enrollee on June 14, 2021, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (CPT code(s): 1HB11, G0151, G0157, 
Q5003) provided to the enrollee from May 21, 2020, through June 19, 2020. 
 
You asked the Plan to pay for the home health services. You say that the enrollee lives in a long-term nursing 
facility; therefore, the codes on this claim are correct. The Plan denied your request. The Plan says the 
Medicare rules have not been met. The Plan states if the provider determines that a billing error occurred 
during the initial submission of the denied claim, they will accept a submission of a corrected claim to consider 
services for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per Medicare billing guidelines, the provider did not bill one of the three Q codes (Q5001, Q5002, and Q5009). 
We find the Medicare rule for payment of these May 21, 2020, through June 19, 2020, claim has not been met. 
Based on this information, we decided that Medicare rules for coverage of the home health services have not 
been met. Therefore, we decided that the Plan does not have to pay for home health services (CPT code(s): 
1HB11, G0151, G0157, Q5003) provided to the enrollee from May 21, 2020, through June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services (G0483) provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photorefractive keratectomy (CPT code S0810) provided to 
the enrollee on December 4, 2020. 
 
You asked the Plan to pay for the service. You say that the enrollee went to this provider because they were 
having significant problems with balance. The Plan denied your request. The Plan says this service is not 
covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. It was determined that CPT Code 
S0810 photorefractive keratectomy is not on the fee schedule as a covered service. Therefore, we decided that 
the Plan does not have to pay for photorefractive keratectomy (CPT code S0810) provided to the enrollee on 
December 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(CPT code 99239) provided to the enrollee on February 2, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99239 (1 Unit) remains not supported. The submitted discharge summary does not support hospital 
discharge day management of more than 30 minutes was performed. A documented duration of time of 31 
minutes or more is required to support this code. Therefore, the billed service cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 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 hospital discharge day management; more than 30 minutes (CPT code 99239) 
provided to the enrollee on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight test (CPT code 81479) provided to the enrollee on 
June 21, 2021. 
 
You asked the Plan to pay for the testing. You say that the service should be covered. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. This claims appeal is for 81479 
(GeneSight Psychotropic) a pharmacogenomic test performed on June 21, 2021, was ordered specifically for 
F29 (unspecified psychosis). Policy Article A58324 does not include F29 as part of the Group 1 medical 
necessity coding group. MolDx Dex Diagnostic exchange review shows that the GeneSight Psychotropic is 
non-covered whereas the GeneSight Psychotropic Multi-Gene is covered. This request for payment of 
GeneSight Psychotropic (the test performed) 81479 is therefore denied as not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pay for GeneSight test (CPT code 81479) provided to the 
enrollee on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth series of x-rays received on June 28, 2021. 
 
You asked the Plan to pay for the services. You say that you do not understand why the bitewings were paid as 
part of the full mouth series of x-rays. The Plan denied your request. The Plan says the procedure remains 
denied, and no payment will be made. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers bitewing x-
rays once per year. 
 
The case file shows that the plan paid a separate claim for bitewing x-rays on date of service August 19, 2021. 
The denial for the full mouth series of x-rays is two-fold. Firstly, the only type of x-ray covered by the plan is 
for bitewing x-rays. Additionally, the plan already paid for bitewings during the 2021 calendar year, so the 
bitewing portion of the full mouth series cannot be paid for again. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a full mouth series of x-rays received on June 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided July 2, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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. 
 
We find that CPT code 99284 is not supported in the medical record. Specifically, this service was not billed 
with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of 
the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency room services (99284) provided July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from June 3, 2020, 
through June 30, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the documentation and clinical picture of the 
treating physicians throughout the record best supports the DRG 853. The Plan denied your request. The Plan 
says that there is no dispute that the enrollee required hospitalization, or the services were medically necessary. 
The Plan states the payment integrity post-service post-pay clinical validation audit shows that the provider has 
reported inpatient hospital services with the incorrect DRG. 
 
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. It appears that the plan's contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision. The record clearly indicates that the Plan 
reviewed medical records and did not forward them. Therefore, we decided that the Plan has to pay for 
inpatient hospital care provided to the enrollee from June 3, 2020, through June 30, 2020.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on April 9, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network laboratory services. You say that this is an independent laboratory and does not receive any patient information until after services are rendered. You state the enrollee was seen by an in-network physician with no control over the laboratory used and should not be penalized by having this claim processed as out-of-network. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 laboratory services provided to the enrollee on April 9, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869, 
22870, 00630). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex Superion device. You say that other treatments 
have failed. The Plan denied your request. The Plan says this is not indicated. 
 
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 insertion of a Vertiflex Superion 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show 
it is safe and effective. 
 
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 insertion of a Vertiflex Superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device (22869, 22870, 
00630).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99233) provided March 1, 2021 to March 8, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has 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. 

We find that CPT code 99233 is not supported in the medical record. Specifically, the claim was not billed with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99233) provided March 1, 2021 to March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show why the enrollee is not a candidate for radiofrequency ablation. 
 
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 guidelines limit diagnostic facet injections to two sessions. The guidelines do not support repeated 
facet blocks, as the next stop is radiofrequency ablation. The request to repeat the facet injection is deemed not 
medically reasonable or necessary 
 
We looked at this physician's review, the file, and Medicare rules. The case file does not contain any 
documentation indicating why radiofrequency ablation as the next step is not appropriate. 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 therapeutic facet joint injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The 
Plan says 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 pre-approve the Superion interspinous spacer 
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Vertiflex Superion spacer is experimental. More research is 
needed to show safety and efficacy of this device. 
 
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 Superion interspinous spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport wheelchair provided to the enrollee on April 16, 
2021. 
 
You asked the Plan to pay for the wheelchair. You say that the plan representative stated that this would be 
covered at 80% from any vendor with a physician order. The Plan denied your request. The Plan says there was 
no authorization on the file for the wheelchair. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Additionally, Medicare rules say that services must be provided by 
providers who are enrolled in the Medicare program. 
 
The item at issue in this appeal is for use outside of the home, and was provided by a vendor that does not 
participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for a transport 
wheelchair provided to the enrollee on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 2, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network laboratory services. You say that the claim should be paid. 
The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 laboratory services provided to the enrollee on 
August 2, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1845, L1846). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury or knee surgery, or objective evidence of knee 
instability. 
 
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 based on the medical records provided, there is no documentation of a recent injury or surgery of the 
knees or objective evidence of knee instability which would qualify for the orthosis. 
 
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 a knee orthosis (L1845, L1846).