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

 
We decided that the Plan does not have to pay for a PrismRA molecular pathology procedure (81479) provided 
on December 29, 2021. 
 
You asked the Plan to pay for a PrismRA procedure. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because 
medical records are needed to determine the clinical utility of the service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests must 
undergo an application and technical assessment process through the MolDX contractor. MolDX will only 
cover and reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that 
meets the Medicare reasonable and necessary requirement.  
We looked at the file and Medicare rules. We found that the service at issue is not covered through MolDX. 
Based on this information, we decided that Medicare rules for coverage of a PrismRA procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for a PrismRA molecular pathology procedure 
(81479) provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the urgent care visit provided on February 13, 2022. 
 
You asked the Plan to pay for the urgent care visit. You say that this was medically necessary care that was 
billed with the correct diagnosis. The Plan denied your request. The Plan says that the diagnosis and procedure 
do not match. A corrected claim is needed. 
 
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 has not provided any cogent denial rationale in this case. The claim 
denied indicating that the diagnosis does not match the procedure. The enrollee presented with pain and 
swelling, which was found to be related to an abscess. Evaluation and management services were provided. 
There is no clear reason that the diagnosis code is not appropriate for this visit. Though this is a dental issue, no 
dental treatment was provided or billed. We find that denial of payment for this service is not supported. 
Therefore, we decided that the Plan has to pay for the urgent care visit provided on February 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has vertebrogenic low back 
pain. The symptoms are aggravated by bending, daily activities, lifting, standing and walking. She has multiple 
plausible pathologic sources of significant pain generation. The non-radiating midline back pain, the noted 
pain-aggravating, and pain-relieving factors, and intact neurologic exam were/are all non-specific to any 
pathologic entities. The documetation lacks evidenced findings supportive of the spinal vertebral bodies as the 
overwhelming primary pain generators. The Intracept procedure is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0394T billed for date of service October 18, 
2021. 
  You asked the Plan to pay for procedure code 0394T. You say that the medical notes justify billing 0349T 
because the enrollee received treatments at 2 separate sites. You say that only one unit was paid, and additional 
payment should be made. The Plan denied your request. The Plan says payment for code 0394T is bundled into 
payment for code 77401. 
 
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 0394T 
is a column II code to column I code 77401. This code 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 0394T billed for date of service October 18, 
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 you do not have documented skilled nursing needs or documented skilled therapy 
needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 5, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 24, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility, and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
March 11, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the patient has always seen this provider as 
their primary care physician (PCP), and wanted to continue for continuity of care. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan. The Plan also says that the services 
were not referred by a network provider. The Plan also says that they have also determined that these services 
are not urgent or emergent, nor were they approved in advance. 
 
 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 April 25, 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 wound care supplies provided on April 27, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that the enrollee received and used surgical 
dressings as part of wound care treatment. You say the supplies should be paid for. The Plan denied your 
request. The Plan says the enrollee went to an out-of-network provider without a prior authorization. The Plan 
also found that the services were neither urgent nor 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 wound care supplies provided on April 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plastic surgery services (procedure code 19380) provided to 
the enrollee on November 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 19380 is not supported by the records submitted. 
 
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 asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records submitted. Our reviewer found that the documentation in 
the Report of Operation does not include documentation of significant removal of tissue, re-advancement 
and/or re-inset of flaps in autologous reconstruction. 
 
We looked at this coder's review, the file, and Medicare rules. 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 plastic surgery services (procedure code 19380) provided to the enrollee on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the polycarbonate lenses (V2784) provided May 5, 
2022. 
 You asked the Plan to pre-approve the polycarbonate lenses. You say that you should not be responsible for 
this amount. The Plan denied your request. The Plan says this upgrade is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Though the Plan offers vision benefits in excess of Medicare 
coverage, the polycarbonate lenses are not among those covered services. Therefore, we decided that the Plan 
does not have to pre-approve the polycarbonate lenses (V2784) provided May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service April 15, 
2022. 
 You asked the Plan to pay for procedure code 74176. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74177. 
 
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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service April 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on December 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that the patient is in a nursing home for which a specific 
provider has an 
exclusive contract with the facility and only the specific provider can come into the facility to perform services. 
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 an x-ray provided on December 1, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that your laboratory performed all the tests that 
were ordered by the referring physician. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
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 May 11, 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 laboratory services rendered on April 16, 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 services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that a DEX-Z code is required for billing of gene 
expressing profiling. 
 We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
DEX-Z code. 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 
April 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided form February 1, 2022, through 
February 17, 2022. 
 
You asked the Plan to pay for physical therapy. You say that physical therapy was provided by the therapy 
team, to the enrollee who is a long-term resident at the facility. You say that the services were necessary, and 
the provider should be compensated. The Plan denied your request. The Plan says the claim was not submitted 
with the required modifiers to process and pay claim. 
  The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must continue to report 
modifier GN, GO or GP for any therapy code on the list of applicable therapy codes 
 
We find that the physical therapy services are not supported in the medical record. Specifically, CPT codes 
97112, 97116 and 97530 are considered therapy codes. This means that CPT codes 97112, 97116 and 97530 
require a therapy modifier of GN, GO or GP. The claim shows that these codes were not billed with a required 
therapy modifier. Based on this information, we decided that Medicare rules for coverage of physical therapy 
have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided form 
February 1, 2022, through February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of excessive skin of the abdomen and 
infraumbilical panniculectomy for the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is insufficient clinical documentation that would indicate the necessity for 
this procedure. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has a large pannus. The record provided does not include 
documentation of failed conservative therapy or the presence of functional limitations. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on the reviewer's findings, the 
requested procedures would be considered cosmetic. Based on this information, we decided that Medicare rules 
for coverage of the procedures have not been met. Therefore, we decided that the Plan does not have to pre-
approve excision of excessive skin of the abdomen and infraumbilical panniculectomy for the enrollee.