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

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on January 31, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code 99233 is not supported in the medical record. Specifically, diagnosis code J12.82 is not 
a valid primary diagnosis code. The underlying cause must be coded first. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99233) provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotic (L3040)provided on November 29, 2022. 
 
You asked the Plan to pay for the orthotic. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 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 payment for code L3040 is not supported in the medical record. Specifically, the claim was billed 
with a right-sided diagnosis code (M79.671). However, code L3040 was billed with both modifiers LT and RT. 
It is inappropriate to bill modifier and LT and RT for a right-sided diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the orthotic have not been met. Therefore, we decided that the 
Plan does not have to pay for the foot orthotic (L3040)provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
September 7, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service September 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone billed with code G2078 
for November 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2078 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the take home supply of methadone 
billed with code G2078 for November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on October 31, 2022.  
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says this test has not met the coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 11, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery to prevent thromboembolism. The Plan denied your request. The Plan says 
equipment used during surgery is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
September 8, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you have provided nursing notes 
to support payment. The Plan denied your request. The Plan says the billed codes are 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of an SNF admission. The Plan denied your request. The Plan says the request for a SNF admission 
is not medically necessary. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, 
provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. The records support that services in the home or an 
assisted living facility with home health care or in a long-term care facility on a part time basis are appropriate 
in this case. 
 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on September 26, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you moved, and you needed to establish a 
new primary care physician. The Plan denied your request. The Plan says the Plan has paid the maximum 
amount covered by your Plan for this service. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on 
September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed with code A4595 for 
October 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. The 
documentation shows a tracking number that does not confirm the items at issue were delivered. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrical stimulator supplies billed with code A4595 for 
October 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 22 or more drug classes (G0483) 
provided on December 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that due to the expansive clinical value of the 
testing you do that benefits the enrollee, you ask for reconsideration of the denial and request payment in full 
for the testing. The Plan denied your request. The Plan says the documentation does not support that the 
services rendered were medically necessary. 
 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 definitive drug testing, 22 or more drug classes 
(G0483) provided on December 5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry (93229) 
provided on August 12, 2022.  
You asked the Plan to pay for the external mobile cardiovascular telemetry. The Plan denied your request. The 
Plan says the denial is being upheld due to the provider not submitting documentation to support the coding 
criteria for the code billed that contains any documentation from date of service August 12, 2022. 
 
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 external mobile cardiovascular 
telemetry. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of syncope and documented atrial fibrillation. 
There is no supportive evidence that the ordering practitioner documented any standard, non-Mobile Cardiac 
Outpatient Telemetry (MCOT), ambulatory electrocardiogram monitoring. Our reviewer also found that in 
summary, there is insufficient documentation to support the medical necessity for an MCOT monitor in this 
enrollees clinical management. 
 
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 external mobile cardiovascular telemetry have not been met. Therefore, we 
decided that the Plan does not have to pay for the external mobile cardiovascular telemetry (93229) provided 
on August 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on April 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the ordering provider is valid and able to order 
Medicare lab services. The Plan denied your request. The Plan says that its decision to deny these services was 
correct. 
 
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. Specifically, the Plan has sent us a very scant case file with very little 
information.  It includes no copies of denial notices explaining why they are denying the services in question.  
It includes no case narrative explaining the chronology of events in this case.  Further, it appears from your 
appeal that the Plan may have denied the lab service sin dispute because they claim that the provider has opted-
out of Medicare.  However, the Plan has provided no proof of this. In addition, you have asserted that this 
provider is registered with the Provider Enrollment, Chain, and Ownership System (PECOS) to be able to order 
lab services.  The Plan has failed to disprove this assertion.  The burden is on the Plan to show why its denial 
was correct.  Due to its failure to provide any of this information, we find that the Plan has not met this burden. 
Therefore, we decided that the Plan has to pay for lab services provided on April 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xT Assay testing provided on March 14, 2022.  
You asked the Plan to pay for Tempus xT Assay testing. You say that this testing was medically necessary and 
reasonable for this enrollee. The Plan denied your request. The Plan says the records do not show that the 
enrollee has recurrent, relapsed, resistant (refractory), cancer that has spread from original site to another part 
of the body (metastatic), or advanced stages III or IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Tempus xT Assay testing have not been met. Specifically, the documentation does not support that 
the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, we 
decided that the Plan does not have to pay for Tempus xT Assay testing provided on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 200 units of Botox. 
 
You asked the Plan to pre-approve 200 units of Botox. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botulinum toxins (Botox, Dysport, Xeomin and 
Myobloc), will be considered medically reasonable and necessary when administered for treatment of certain 
FDA-labeled indications and Off-label 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 200 units of Botox. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found review of the information shows 
that the enrollee has contracted muscles. The enrollee has had Botox injections and had a good result. 
However, per the Botox package insert, 400 units is allowed per injection for contracted muscles. The review 
has determined that the enrollee does not meet coverage criteria for the requested dosage based on the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 200 units of Botox have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 200 units of Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment identified with code G2067 
provided on September 5, 2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that only an entity enrolled with Medicare as an OTP 
can bill for medication assisted treatment identified with code G2067. 
 
We looked at the file and Medicare rules. Review of the file shows that the services were rendered in a certified 
OTP facility; however, the rendering provider billed for the services and not the OTP facility. This means the 
claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
medication assisted treatment have not been met. Therefore, we decided that the Plan does not have to pay for 
the medication assisted treatment identified with code G2067 provided on September 5, 2022.