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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81292, 81301, 
81162, 81295, 81298, 81317, 81321, 81194, 81401) provided on May 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The denial remains 
upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. 
 
CPT code(s): 81162, 81295, 81298, 81317, 81321, 81194, and 81401, remain not supported. The place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an Off Campus-Outpatient Hospital setting POS 19. Also, the laboratory results submitted indicate the 
specimen was collected on May 13, 2021, and received by the lab on May 14, 2021. Therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 
81292, 81301, 81162, 81295, 81298, 81317, 81321, 81194, 81401) provided on May 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion subcutaneous cardiac rhythm monitor (33285, 
C1764). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the records do not show that the 
requested procedure meets the medically necessary criteria. 
 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found While the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an implantable loop recorder. In summary, there is insufficient documentation to support the medical necessity 
for insertion of an implantable loop recorder 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion subcutaneous cardiac rhythm monitor (33285, C1764).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheeled walker. 
 
You asked the Plan to pre-approve the walker. You say that your walker was not made for your size. The Plan 
denied your request. The Plan says your walker has not reached its reasonable useful lifetime. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and the rules. The file shows that you have a walker, provided in 2021. Your current 
walker serves the same purpose as the requested walker. The case file does not contain documentation that your 
current walker has irreparable damage and requires replacement. 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 pre-
approve a wheeled walker.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided from May 1, 2021, to May 
4, 2021. 
 You asked the Plan to pay for the nursing facility care. You say that there are multiple claims that have been 
submitted. You also say that they should be paid. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the nursing facility care provided from May 1, 2021, to May 
4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
diagnosis can be made without testing. 
 
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 requested testing. Our physician 
reviewer found that the documentation shows the enrollee claims having memory impairment, although there is 
no documentation in the neurologic exam notes that were presented. This testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain. 
The enrollee in this case, does not meet the criteria as she is not showing severity of symptoms that would 
warrant this type of diagnostic treatment. Therefore, the request is not medically necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided to the enrollee on December 9, 
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 the provider did not bill as required by Medicare coding regulations. 
 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 11043 
is a column II code to column I code 11044. 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 wound care services provided to the enrollee on December 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, abdomen and pelvis; with contrast material(s) (CPT 
code 74177) provided on December 22, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Review of the records submitted do not indicate that two separate services were performed/supported. The 
appealed claim has billed the same ICD-10 codes. Documentation does not support additional services were 
completed. Only one report was provided with no comparison documented. Therefore, we decided that the Plan 
does not have to pay for CT, abdomen and pelvis; with contrast material(s) (CPT code 74177) provided on 
December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in a VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. COPD is listed as your diagnosis, but there 
are no pulmonary function tests to confirm. You have severe obesity and obesity hypoventilation syndrome 
(OHS), but there is no confirmation of CO2 retention with an arterial blood gas. Medicare does not cover a 
home ventilator for the treatment of OHS, or when used as BiPAP.   
There is no documented failure of BiPAP at home. Our physician reviewer found that your condition does not 
meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and bitewings 
(D0274) provided by a participating provider on November 19, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and bitewings. You say that you have a new 
dentist. You say that you needed these services done. The Plan denied your request. The Plan says the benefit 
limit for D0150 and D0274 has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and bitewings twice a year.  
 
We looked at the file, and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on January 20, 2021, and on May 6, 2021. D0274 was processed at a 50% coinsurance of the allowed amount. The total allowed amount is $31 for D0274. You are being asked to pay the lesser amount of $15 ($31 x 50% = 
$15.50). Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral 
evaluation have not been met and bitewings has been processed correctly. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150), and bitewings (D0274) provided by a 
participating provider on November 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on November 8, 2021, to December 
14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you have been seeing this provider for years, and 
you were never notified that the doctor was out-of-network. The Plan denied your request. The Plan says the 
provider was out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows the provider is out-of-network for Medicare. Therefore, we decided that the Plan does not have to 
pay for the office visits provided on November 8, 2021, to December 14, 2021, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transport and 
clearly exceeds the criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the LTACH services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that long-term acute care hospital (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 patient appears to be more stable and requires only 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. Our reviewer found that there are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Our physician reviewer also found that a transfer to an 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered 
when treatment has completed.  
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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that treatment every 6 weeks is warranted due to the 
enrollee's history and condition. The Plan denied your request. The Plan says the dosing is not a currently an 
accepted practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Entyvio. Our physician reviewer found 
that the enrollee has ulcerative colitis. Entyvio 300mg to be administered every 6 weeks has been requested. 
The requested dosing is not FDA-approved for the enrollee's diagnosis. The dosing is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is 
not listed as not indicated, not supported or not recommended in any of the compendia. The requested dosing 
does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheostomy (31600-AS) provided on November 27, 
2021. 
 You asked the Plan to pay for the tracheostomy. You say that all services were medically necessary and should 
be paid as billed. The Plan denied your request. The Plan says this service was billed with modifier AS which 
indicates "physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery". 
According to the National Physician Fee Schedule Relative Value File, code 31600 has an "Assistant at 
Surgery" indicator of 1. This means that statutory payment restrictions for assistance at surgery applies to this 
procedure. Assistants at surgery may not be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that services with an Assistant 
at Surgery indicator of 1 have a statutory payment restriction for assistants at surgery. Assistant at surgery for 
these services may not be paid. 
 
We find that CPT code 31600-AS is not supported in the medical record. Specifically, this service has an 
Assistant at Surgery indicator of 1 and was billed with modifier AS for assistant at surgery. Based on this 
information, we decided that Medicare rules for coverage of the tracheostomy have not been met. Therefore, 
we decided that the Plan does not have to pay for the tracheostomy (31600-AS) provided on November 27, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that this is medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
receiver.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0482) provided on March 11, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0482 remains not 
supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on March 11, 2021, and received by the lab on March 12, 2021, and received by the lab 
on March 12, 2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made to 
obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for 
the drug testing (CPT code G0482) provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (CPT 
code 77063) and screening mammography, bilateral (2-view study of each breast), including CAD when 
performed (CPT code 77067) provided on December 29, 2021. 
 You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. NCCI PTP edit exists between 
77065 and 77067. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, 
however, an appropriate NCCI modifier was not billed with this PTP code edit. 
 
NCCI PTP edit exists between 77065 and 77063. This PTP edit has a modifier indicator of 1, modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code 
edit. Therefore, we decided that the Plan does not have to pay for the screening digital breast tomosynthesis, 
bilateral (CPT code 77063) and screening mammography, bilateral (2-view study of each breast), including 
CAD when performed (CPT code 77067) provided on December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.