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

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 9, 
2021, to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 9, 2021, to November 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the services were rendered to the enrollee in good faith. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 a home health visit provided on April 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 93313. You say that this service was necessary and is supported 
in the medical records provided. The Plan denied your request. The Plan says payment for code 93313 is 
bundled into payment for code 00560. 
 
 
 
 
  
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 93313 
is a column II code to column I code 00560. 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 procedure code 93313 billed for date of service March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0466 billed for date of service February 2, 
2022. 
 
You asked the Plan to pay for procedure code G0466. You say that the claim at issue was billed correctly. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 G0466 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code G0466 is a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0466 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0466 billed for date of service February 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 6, 2021, to January 4, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the criteria for a continued 
SNF stay have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 6, 2021, to January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on November 17, 2021. 
 
You asked the Plan to pay for the billed services. You say that the correct place of service was billed. The Plan 
denied your request. The Plan says the code is 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 CPT code. 
 
 
 We find that CPT code 99153 is a technical component code. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the sedation services provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D biopsy provided on October 19, 2021. 
 
You asked the Plan to pay for the WATS 3D biopsy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The WATS 3D biopsy test at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the WATS 3D biopsy provided on October 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee would benefit from 
continued therapy to further combat the negative effects that chemotherapy treatment causes to help prevent 
them from falling and causing more significant harm to themself. The Plan denied your request. The Plan says 
the requested service does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested therapy is generally accepted as a specific and 
effective therapy for the enrollee's weakness, imbalance, and gait abnormality after chemotherapy. A physical 
therapy note dated July 29, 2022, indicated that the enrollee has been going to the gym and performing their 
home exercise program. Our reviewer found that the enrollee's Dizziness Handicap Inventory Scores have 
remained the same as well as motor strength and balance skills. The enrollee's Timed Up and Go (TUG) test 
score continues to place them at risk for falls, but it is unclear whether they continue to make objective 
progress with therapy and requires the continued oversight of a skilled physical therapist versus being able to 
makes gains with an independent home exercise program. Our physician reviewer found that therefore, the 14 
visits of additional therapy cannot be considered 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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 additional physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 9, 
2021, to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 9, 2021, to November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive pharmaco-genetic testing 81225, 81226, 
81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 
81479, 81407, 81406 and 81238 provided May 12, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition The Plan denied your 
request. The Plan says the records do not support medical necessity. The records did not indicate this test was 
performed for the purpose of medication evaluation in either proposed treatment plan or evaluation of an 
established treatment plan. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient documentation of what drugs are being considered and for what 
indications, to ensure the test performed was reasonable and 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for comprehensive pharmaco-genetic testing 81225, 81226, 81227, 81230, 81231, 81232, 
81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 81479, 81407, 81406 and 81238 
provided May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulator trial procedure and implantation. 
 
You asked the Plan to pre-approve sacral nerve stimulator trial procedure and implantation. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention for certain 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 sacral nerve stimulator trial procedure 
and implantation. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found you have benign prostatic hyperplasia and 
lower urinary tract symptoms managed with tamsulosin and finasteride. You continue to have nocturia, 
frequency and urgency. Treatment with myrbetriq helped the urgency but not the frequency or nocturia. 
Prostate size is 22 cc and PVR is 38 mL. There is no documentation that you have tried anti-cholinergic agents. 
Although you state you have eliminated coffee and beer from your diet and kept a diary, there was no diary 
submitted for review or documentation from the provider of the diary. Additionally, the documentation 
submitted by the provider showed your obstructive symptoms were controlled with Flomax and 
neuromodulation is not indicated in enrollee with obstruction. Therefore, the enrollee does not meet criteria for 
the requested 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 sacral nerve stimulator trial procedure and implantation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve sacral nerve stimulator trial procedure and 
implantation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on May 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that the services were provided to the enrollee in a 
nursing facility and the facility is responsible for obtaining prior authorization. The Plan denied your request. 
The Plan says the services were not approved prior to the date of service and were not urgent or emergent in 
nature. The Plan also says that the services provided to the enrollee could have been rendered by a participating 
provider. 
 
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 eye exam provided 
on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 2 power wheelchair. 
 
You asked the Plan to pay for the power wheelchair. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically reasonable and necessary. Our physician reviewer found that the enrollee has a mobility limitation that impairs her MRADLs, however the documentation does not 
reveal a home assessment indicating that the requested power wheelchair can safely be used in the home and 
has adequate maneuvering space to effectively participate in MRADLs and significantly improve MRADL 
participation in the home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pay for a group 2 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided by a 
participating provider on May 11, 2022. 
 
You asked the Plan to pay for a 2D oral/facial photographic image. You say that these were routine services. 
The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 2D 
oral/facial photographic image (D0350) provided by a participating provider on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on June 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received 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 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 hospital outpatient clinic visit provided on June 
14, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the GeneSight testing provided to the enrollee on 
December 2, 2021. 
 
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing. 
 
Medicare does not currently consider the denied testing to be reasonable or necessary. 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 pre-approve the GeneSight testing provided to the enrollee on December 
2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that an authorization is not needed for the services that 
were rendered. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 provided on June 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 8, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 81291, 0031U, 0032U, 0033U, 81238 and 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services were 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 testing provided on 
April 8, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 81291, 0031U, 
0032U, 0033U, 81238 and 81407.