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

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 9, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says individual gene codes should not be 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 looked at the file and the rules. The panel in this case was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the attached records support this procedure 
was performed by the provider and the claim denied in error. You say that the claim should be reviewed and 
reprocessed for reimbursement. 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 January 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on February 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that no prior authorization was obtained. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The record 
shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for 
laboratory work provided on February 28, 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 70450 billed for date of service March 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and attached reports support the level of service. You say that the claim should be reconsidered for 
processing. 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 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #12 (D2752). 
 
You asked the Plan to pre-approve a crown. You say that you need the crown because the whole filling is gone. 
The Plan denied your request. The Plan says that there is no evidence of decay or a missing crown to support 
the need for a replacement. 
 
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. The Plan did not provide a clear copy of the medical records they used in 
making their decision. The Plan has not supported their decision to deny your request. Therefore, we decided 
that the Plan has to pre-approve a crown on tooth #12 (D2752).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Orthovisc or Supartz FX. The documentation does not support that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 29, 2021 billed 
with codes 81225, 81226, 81227, 81230, 81291 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
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 
November 29, 2021 billed with codes 81225, 81226, 81227, 81230, 81291 and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 27, 2021 billed with codes 81206 and 81292.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastectomy bra billed for services on January 4, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says valid proof of 
delivery has not been provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the mastectomy bra billed for services on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2021 billed with 
codes 81220, 81226, 81227, 81230, 81241, 81291, 81335, 81479, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was not billed with the appropriate coding. 
 
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 
May 19, 2021 billed with codes 81220, 81226, 81227, 81230, 81241, 81291, 81335, 81479, and 81355.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve continuation of an inpatient admission from June 5, 2022, to 
June 6, 2022. 
 
You asked the Plan to approve continued inpatient care. You say that additional time is medically necessary for 
the enrollee in this setting. The Plan denied your request. The Plan says while inpatient care was medically 
necessary from May 31, 2022, through June 4, 2022, the enrollee was stable for transfer to a lower level of care 
after this date. Therefore, the additional days are denied as 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 approve continued inpatient care. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital for a hip fracture after a mechanical fall on 
May 31, 2022, and had open reduction and internal fixation (ORIF) surgery on June 1, 2022. Complications 
included hypotension, which persisted until June 4, 2022. There is no documentation that as of June 5, 2022, 
there was any medical instability that would prevent transfer to the next level of care, which in this case is 
skilled nursing. Continued acute care services are not medically necessary for June 5, 2022, forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient care have not been met. Therefore, we decided that the Plan 
does not have to approve continuation of an inpatient admission from June 5, 2022, to June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 4, 2021. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says a panel 
code should be billed rather than the individual gene codes. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes, 
the laboratory shall report only one unit of service of one code. 
 
We looked at the file and Medicare rules. The lab service at issue 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 billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental and more research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee qualifies for LTACH 
admission, and it is the safest and most efficient care for the enrollee. The Plan denied your request. The Plan 
says the clinical assessment does not support the expectation of a stay to be at least 25 days. The enrollee's 
medical needs are being met in the current acute setting. The LTACH would add no additional services. With 
additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of 
care can be determined. 
 
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 that the enrollee appears to be somewhat unstable at this time and requires short-term 
additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as the enrollee is not yet stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for gene analysis provided on January 11, 
2022. 
 
You asked the Plan to waive the copayment for the gene analysis. You say that you believe there should be no 
enrollee responsibility for routine labs. The Plan denied your request. The Plan says you have been charged the 
correct copayment amount 
 
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 $120 
copayment for INR test strips and specialty genetic testing.  
 
You have been asked to pay a $120 copayment for the gene analysis. The gene analysis falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 gene analysis provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on November 22, 2021. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment falls within the Durable medical equipment (DME) and related supplies 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 Oxygen equipment (E0431, E1390) provided 
on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2021, billed with 
codes 81220, 81225, 81230, 81238, 81240, 81241, 81291, 81355, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the services have not been billed 
correctly. 
 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 
March 31, 2021, billed with codes 81220, 81225, 81230, 81238, 81240, 81241, 81291, 81355, 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry coded 
83789 provided on February 23, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 83789 is a column II code to column I code 
G0481. While this claim was billed with modifier -59, the medical records provided do not show that the 
service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that 
Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided 
that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry coded 83789 
provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on March 15, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that this is your first dental visit in a long time. The 
Plan denied your request. The Plan says the enrollee did not enrollee in the platinum; therefore, 
these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220 and 
D0230) provided by a participating provider on March 15, 2022.