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

 
We decided that the Plan does not have to pay for GeneSight Psychotropic Assay (81479) provided on April 6, 
2022. 
 You asked the Plan to pay for genetic testing. You say that this service was denied in error and should be paid 
as a covered benefit. The Plan denied your request. The Plan says the requested testing reported on April 8, 
2022, remains denied based on lack of medical necessity for the 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 genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the test was ordered for the diagnoses of major 
depressive disorder (ICD-10 code F33.1) and anxiety disorder (ICD-10 code F41.1). The GeneSight Order 
Medical Necessity Documentation for GeneSight Psychotropic dated April 6, 2022, listed the enrollee's failed 
medications, which included Lexapro (escitalopram), Zoloft (sertraline), Klonopin (clonazepam), Lamictal 
(lamotrigine), and Effexor (venlafaxine). Though the order stated that Viibryid (vilazodone), Trintellix 
(vortioxetine), Cymbalta (duloxetine), and Elavil (amitriptyline) were being considered for augmentation or 
starting/switching to, there is no documentation of such provided in the medical records. The provider planned 
to continue the enrollee's current medications and the provider explicitly stated that GeneSight testing was 
ordered to gain "collateral information. The review has determined that the requested genetic testing in this 
case is not medically reasonable and necessary for payment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for GeneSight Psychotropic Assay (81479) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS procedure (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS procedure. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS procedure (33289, C2624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on September 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing panel was not billed with appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic panel tests are considered a single 
procedural service, so 1 code must be submitted for the panel.  
 
We looked at the file and Medicare rules. This test panel was not billed with a single procedure code in 
accordance with Medicare billing rules. Based on this information, we decided that Medicare rules for coverage 
of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic panel 
testing provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) (e.g., myeloproliferative 
disorder) gene analysis, p. Val617Phe (V617F) variant (81270). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of 
the requested testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says that without the results of BCR-ABL, the request 
cannot be approved. The medical records do not show a negative test result of BCR-ABL. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) 
gene analysis, p. Val617Phe (V617F) variant (81270).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 23, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are not responsible for the 
copayment because the diagnostic testing was performed in a specialist office, which you have already paid for. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $60 copayment for an ultrasound. This item/service falls within the Medicare-
covered diagnostic radiology services 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 
an ultrasound provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99204) to be provided by a tertiary care 
provider. 
 
You asked the Plan to pre-approve the tertiary level of care. You say that the service is medically necessary. 
The Plan denied your request. The Plan says tertiary care 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 tertiary level of care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you require evaluation for a rotator cuff tear. The record 
indicates that you have received two evaluations at the community standard level of care that agree with the 
same treatment plan suggested. The Plan has indicated that such care is available within the standard network. 
The record provided does not demonstrate the medical necessity of the requested service. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the tertiary level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the office visit (99204) to be provided by a tertiary care provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from June 1, 2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that your bill is for service beyond 20 days 
permitted by Medicare is not valid. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $188 
copayment for each day for days 21 to 41 in a skilled nursing facility.  
 
You have been asked to pay a $1,678.50 copayment for a 34-day SNF stay that started on May 27, 2022. You 
are responsible for a $0 copayment for days 1 to 20 and a $188 copayment per day for days 21 to 34 ($188 per day x 14 days = $2632), however, you met your out-of-pocket maximum partway through this claim. This 
item/service falls within the skilled nursing facility 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 skilled nursing facility (SNF) stay provided from June 1, 2022, to June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) and eye refraction 
(92015) provided on October 17, 2022. 
 
You asked the Plan to waive the copayment for the eye exam and eye refraction. You say that you feel this 
should be covered in full. You also say that you have never had to pay for an annual eye exam. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for routine eye examinations under the Vision Care benefit category.  
 
 
 
 
 You have been asked to pay a $50 copayment for the eye exam and eye refraction. This item/service falls 
within the Vision Care 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 the eye 
exam (92014) and eye refraction (92015) provided on October 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you verified the patient's insurance coverage 
over the phone. The Plan denied your request. The Plan says procedure code 99601 is considered bundled and 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a status indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ciliary body destruction (66710) provided on October 27, 
2022. 
 
You asked the Plan to pay for ciliary body destruction (66710). You say that the service should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ciliary body destruction 
(66710) provided on October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar 
spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-level degenerative 
disease including severe central canal stenosis at the level requested for treatment. The record does not 
document that the enrollee is not indicated for surgery at no more than two levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 record indicates that the enrollee has a diagnosis of metastatic prostate cancer. The Food and Drug 
Administration has not stated that the requested drug as prescribed is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug as prescribed in the enrollee's specific clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary. 
The Plan denied your request. The Plan says the requested CT scan is not reasonable and 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 reviewer says that the 
CT scan of the heart is not medically necessary. Our physician reviewer found that the enrollee has 
hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris status post stents 
in 2011 and again in 2020. The computed tomography angiography (CT/CTA) scan of the heart with contrast 
was requested and denied. The enrollee did not report any symptoms of chest pain or shortness of breath and 
initial assessment in the documentation does not describe active symptoms to justify this test at this time. 
 
  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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration for the 
denied services of diagnostic testing for the enrollee. The Plan denied your request. The Plan says the enrollee 
is no longer an active member with the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee is no longer an active member 
with the Plan as of December 31, 2022; therefore, the services cannot be covered. Based on this information, 
we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genetic testing (81479).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from October 23, 2022, to 
October 28, 2022. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says this claim was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that home health agencies must report an additional 
line item with the same revenue code and date of service, reporting one of the three Q- codes to represent the 
location where home health services were provided.  
 
We looked at the file and Medicare rules. This claim was not billed with the applicable Q- code. Based on this 
information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, 
we decided that the Plan does not have to pay for home health care provided from October 23, 2022, to October 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve the dental services. You say that your crown is too big, and the color is not 
right. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 27, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on June 14, 2022. 
 
You asked the Plan to pay for a crown. You say that you do not have the money to pay for this. The Plan 
denied your request. The Plan says the denied services have been correctly denied. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140) provided on October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are cover for $2,000 annually. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 17, 2022. Two 
extractions were covered with a 50% coinsurance. The remaining six extractions have been denied. Therefore, 
we decided that the Plan does not have to pay for extractions (D7140) provided on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the longer the enrollee goes without treatment the 
weaker the enrollee will get. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee continues to have skilled therapy needs; however, the documentation 
does not support that the enrollee would require skilled rehabilitation in an IRF with rehabilitation services 15 hours per week under regular physician supervision. The enrollee can receive further care at a lower level of 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.