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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this was coded correctly, and the charges are 
coded from different batches. You say that the supporting medical notes should be reviewed, and the claim 
reprocessed accordingly. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 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 70450 is a column II code to column I code 70496. 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 70450 billed for date of 
service March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 4, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 17, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the specimens were sent to your laboratory 
from the referring provider. The Plan denied your request. The Plan says the rendering and referring providers 
are both OON providers and there was no approved 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 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 on May 17, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the Plan advised you and the 
provider that this requested code was a covered benefit and that the order could be placed. The Plan denied 
your request. The Plan says the requested compression stockings do not meet the statutory definition of a 
dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (urothelial), mRNA, gene expression profiling 
by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing 
urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided November 23, 
2021. 
 
You asked the Plan to pay for CxBladder detect. You say that you would appreciate prompt review of this 
information and authorization of coverage for the CxBladder Detect test for this enrollee. The Plan denied your 
request. The Plan says CxBladder detect does not fall into the reasonable and necessary test types and is not a 
covered genetic test for the bladder. 
 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. Based on this information, we decided that Medicare rules for 
coverage of CxBladder detect have not been met. Therefore, we decided that the Plan does not have to pay for 
the oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes 
(MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for 
having urothelial carcinoma (0012M) provided November 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you require special care because your spouse is not 
able to take for you herself. The Plan denied your request. The Plan says your needs can be met at a lower level 
of care. 
 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 pre-approve 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 is a male with a history of stroke with associated hemiplegia. He is 
currently residing at home and had a recent primary care visit where SNF admission was requested. The 
clinical documentation shows that the enrollee has several medical conditions; however, there is no 
documentation to show that the enrollee requires daily skilled therapy or daily home health nursing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this level of care is medically necessary 
to avoid multiple re-admissions to short-term acute care. The Plan denied your request. The Plan says there is 
no advantage in moving the enrollee from the current acute care hospital to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid repair/modification (V5014) provided by a 
non-network provider. 
 
You asked the Plan to pay for the hearing aid repair/modification. You say that you feel the Plan should cover 
this service because it was cheaper than getting a new set of hearing aids, which the Plan would have covered. 
The Plan denied your request. The Plan says hearing aids must be purchased through the Plan's hearing aid 
vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid repair/modification have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aid repair/modification (V5014) provided by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopic extensive shoulder debridement (29823) 
provided October 19, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that please reconsider this claim for payment. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 25, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the surgical procedure have not been met. 
Therefore, we decided that the Plan does not have to pay for the arthroscopic extensive shoulder debridement 
(29823) provided October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy services. 
 
You asked the Plan to pre-approve the requested services. You say that you have little function in your legs. 
The Plan denied your request. The Plan says you do not show reflux in the veins. The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is only covered under 
certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you had a vein consult for bilateral symptomatic varicose veins. Sclerotherapy was 
performed in the past with good results. Bilateral lower extremity venous insufficiency studies showed 
competency throughout the venous system, without any reflux. The case file does not contain CEAP clinical 
classification. In addition, there was no demonstration of perforator reflux greater than 500 milliseconds or an 
active venous ulcer. Therefore, the records do not show that the treatment is indicated for your condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sclerotherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group 3 power wheelchair with single power option and 
expandable controller (K0856, E2361, E0955, E1002, E1028, E1012, E2620, E2311, E2607). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with single power option and expandable 
controller. You say that this wheelchair and features are medically necessary. The Plan denied your request. 
The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair and accessories are covered when 
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 group 3 power wheelchair with 
single power option and expandable controller. Our reviewer says that the requested group 3 power wheelchair 
with single power option and expandable controller are not medically necessary. Our physician reviewer found 
the documentation does not indicate that the member has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate power tilt. Additionally, the requested electrical 
accessories would not be medically necessary as the member does have use of the upper extremity and could 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
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 group 3 power wheelchair with single power option and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve group 3 power 
wheelchair with single power option and expandable controller (K0856, E2361, E0955, E1002, E1028, E1012, 
E2620, E2311, E2607).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 laboratory 
services provided on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Envyy sleep to stand twin bed and accessories 
coded as E0303 and 99070 purchased December 31, 2021. 
 
You asked the Plan to reimburse you for the total electric hospital bed and accessories. You say that you paid in 
full for the bed and you would like to be reimbursed. The Plan denied your request. The Plan says total electric 
hospital beds are not covered. A standard written order was not provided, and the documentation does not 
indicate a hospital bed with a Medicare approved code was ordered as the items was purchased from a supplier 
that does not bill insurance. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to reimburse you for the Envyy sleep 
to stand twin bed and accessories coded as E0303 and 99070 purchased December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee The Plan denied your request. The Plan 
says the enrollee's needs can be met at a lower level of care such as home with home health rehabilitation 
services or a long-term care facility. 
 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 pre-approve 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 that the clinical documentation states that the enrollee is currently receiving close 
medical monitoring, intense therapy, and daily skilled nursing care, without explanation for why the enrollee 
would now require less intense therapy or a change in medical status. Thus, although the enrollee does require 
skilled therapy and nursing from a practical standpoint, there is no documentation to support transition to a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from October 28, 
2021, to November 22, 2021. 
 
You asked the Plan to pay for the home health care services. You say that no payment has been received. The 
Plan denied your request. The Plan says the non-contracted provider did not submit the request for anticipated 
payment (RAP) claim for services provided until January 31, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from October 28, 2021, to November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on August 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and a 
CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the chest and a CT scan of the abdomen and pelvis. You say 
that the requested CT scan of the chest and CT scan of the abdomen and pelvis are medically necessary. The 
Plan denied your request. The Plan says the requested CT scan of the chest and CT scan of the abdomen and 
pelvis are not medically 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 a CT scan of the chest and a CT scan of 
the abdomen and pelvis. Our reviewer says that the requested CT scan of the chest and CT scan of the abdomen 
and pelvis are not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
low grade follicular lymphoma and limited stage small cell lung cancer. The record indicates that the enrollee 
completed therapy 24 months ago and last had imaging in May 2022 that showed no evidence of disease. The 
provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested service at this time prior to a six-month interval. 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 a CT scan of the chest and a CT scan of the abdomen and pelvis have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of 
the chest and a CT scan of the abdomen and pelvis.