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

 
We decided that the Plan does not have to pay for lab services (81286, 81410, 81411, 81413, 81414) provided 
June 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says these tests are not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers lipid panel testing as 
cardiovascular screening once every 5 years and denies coverage for all cardiovascular genetic risk assessment 
panels for patients with suspected or documented cardiovascular disease. 
 
We looked at the file and Medicare rules. The genetic testing performed is not covered for screening purposes. 
Only lipid panels are covered for cardiovascular disease screening. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (81286, 81410, 81411, 81413, 81414) provided June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller, electronic connection between 
wheelchair controller and 2 or more power seating system motors, and a harness. 
 
You asked the Plan to pre-approve an expandable controller, electronic connection between wheelchair 
controller and 2 or more power seating system motors, and a harness. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an expandable controller, electronic 
connection between wheelchair controller and 2 or more power seating system motors, and a harness. Our 
reviewer says that the services are medically necessary. Our physician reviewer found clinical documentation 
states that enrollee has upper limb deficits including spasticity. In addition, the items would operate 3 power 
functions. Per LCD criteria, the items are 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 an expandable controller, electronic connection between wheelchair controller 
and 2 or more power seating system motors, and a harness have been met. Therefore, we decided that the Plan 
has to pre-approve an expandable controller, electronic connection between wheelchair controller and 2 or 
more power seating system motors, and a harness.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that this injection service is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that in order for facet joint injections to be covered, there 
must be no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patients pain, including but not limited to fracture, tumor, infection, or significant deformity 
 
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 diagnostic MBBs. Our reviewer says 
that the requested MBBs are not medically reasonable and necessary. Our physician reviewer found this 87-
year-old gentleman has chronic low back pain. He has tried physical therapy and is doing a home exercise 
program. He has had 3 Epidural Steroid injections, last of which provided less than 50% pain relief. In this 
case, no imaging has been performed to evaluate whether there are other possible pain generators. At this time, 
the request is deemed not medically reasonable or 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 diagnostic MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the abdomen and pelvis, 
without contrast (74176) provided on January 15, 2020. 
 
You asked the Plan to pay for CT of the abdomen and pelvis. You say that this service is supported as billed 
and was denied as a duplicate in error. The Plan denied your request. The Plan says this is a duplicate 
submission of a claim which has previously been paid by the Plan. The documentation does not support that the 
enrollee received this service twice on the date in question from the same provider. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that a claim or claim line that is determined to be an exact duplicate with respect to certain 
elements is denied. 
 
We find that CPT code 74176-26 is not supported in the medical record. Specifically, the documentation 
provided for review includes a copy of a claim for the same service billed with the same CPT code and 
modifier by the same provider for the same enrollee on the same date. This claim was received by the Plan on 
January 20, 2020, and the Plan provided payment for this service in the form of a check on January 23, 2020. 
The medical records provided do not indicate that the enrollee received this service twice from the same 
provider on the date in question. Based on this information, we decided that Medicare rules for coverage of CT 
of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pay for 
computed tomography (CT) of the abdomen and pelvis, without contrast (74176) provided on January 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve germline prostate panel testing. 
 You asked the Plan to pre-approve germline prostate panel testing. You say that guidelines clearly state that 
germline testing is clinically indicated for the enrollee. You say that the enrollee fits in the very-high risk group 
and the pathology report submitted supports the need for the requested testing. The Plan denied your request. 
The Plan says medical studies have not proven that the requested genetic testing panel is helpful for the 
treatment of the enrollee's health problem. 
 
The Plan follows Medicare rules. Medicare rules say that the results of the testing must directly impact 
treatment or management of the Medicare beneficiary. 
 
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 germline prostate panel testing. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a 
diagnosis of Malignant neoplasm of prostate, with Gleason score of 6 (3+3) and 8 (4+4). The provider writes 
that the enrollee fits in the very high-risk group. The germline genetic testing was ordered on June 16, 2022, to 
determine the type of mutation the enrollee may have, his cancer risk, and to guide the cancer 
prognosis/treatment. The documentation does not support that the results of all off the testing will directly 
impact treatment or management of this Medicare beneficiary. For example, HOXB13 is a prostate cancer risk 
gene that does not have therapeutic implications in advanced disease. The documentation does not support that 
germline prostate panel testing is medically reasonable and necessary 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 germline prostate panel testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve germline prostate panel testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 
8, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the laboratory test should 
have been included in your annual physical and should have not been billed separately. The Plan denied your 
request. The Plan says the proper copayment was applied for the services that was billed from the provider. 
 
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 $10 
copayment for Medicare-covered laboratory tests that are not FIT tests.  
 
  You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall 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 the laboratory services provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the right hand provided on 
March 8, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for 
the right hand provided on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on December 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (G0156) and direct 
skilled nursing services of a registered nurse (RN) (G0299). 
 
You asked the Plan to pre-approve HHA services and RN services. The Plan denied your request. The Plan 
says you no longer meet the criteria for HHA services as you do not have the medical necessity or medical 
complexity needs that warrant this community service type. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 HHA services and RN services. Our 
reviewer says that the requested home health services are not medically necessary, reasonable or coverable. 
Our physician reviewer found you do not have documented, intermittent, skilled needs. You do not have an 
acute illness or injury. Our reviewer also found that your needs are daily and custodial. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HHA services and RN services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve home health aide (HHA) services (G0156) and direct skilled nursing 
services of a registered nurse (RN) (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided 
on January 26, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation shows 
that this service is bundled as part of the global surgical fee because it was reported within the global period of 
the major surgical procedure code 32654 (Thoracoscopy, surgical; with control of traumatic hemorrhage) that 
was billed on date of service January 19, 2022. This means this service is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the subsequent hospital care services have not 
been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services 
coded 99232 provided on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on October 21, 2021. 
  You asked the Plan to pay for the CT scan (70450). You say that you billed 70450-26-77 as it was a distinct 
service and the attached documents support medical necessity. The Plan denied your request. The Plan says an 
appropriate modifier was not billed with this code edit. 
 
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 the CT scan (70450) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodic oral evaluation (D0120), dental 
cleaning (D1110), topical application of fluoride varnish (D1206), comprehensive oral evaluation (D0150), 
resin-based composite-two surfaces, posterior (D2392), porcelain/ceramic crowns (D2740), and the periodontal 
scaling and root planing-four or more teeth per quadrant (D4341) rendered by the out-of-network provider from  
January 18, 2022, through April 11, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider; therefore, they are not payable. 
 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.   
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plan contract states that enrollees must pay 
100% of the costs for dental services rendered by an out-of-network provider. The services in this case were 
rendered by an out-of-network dental provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the periodic oral evaluation (D0120), dental cleaning (D1110), topical application of 
fluoride varnish (D1206), comprehensive oral evaluation (D0150), resin-based composite-two surfaces, 
posterior (D2392), porcelain/ceramic crowns (D2740), and the periodontal scaling and root planing-four or 
more teeth per quadrant (D4341) rendered by the out-of-network provider from January 18, 2022, through 
April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom power wheelchair and accessories (K0861, 
E1028, E2311, E2361). 
 
You asked the Plan to pre-approve a custom power wheelchair and accessories. You say that the requested 
power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the 
requested power wheelchair and accessories do not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 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 custom power wheelchair and 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation indicates the enrollee has a mobility deficit that impairs MRADLs in the home and is not 
ameliorated by a walker, cane, manual wheelchair due to fatigue, pain, and weakness. The enrollee does not 
have a group 3 qualifying diagnosis of a mobility limitation that is due to a neurological condition, a myopathy, 
or a congenital skeletal deformity. The diagnosis of quadriplegia is nonspecific for her. The enrollee's upper 
extremity strength is 4/5. The request for a group 3 power wheelchair with multiple power options exceeds the 
enrollee's medical needs. 
 
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 custom power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom power wheelchair and accessories (K0861, E1028, 
E2311, E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care (PCP) telehealth visit 
provided on February 22, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that this was only a phone consult, 
you did not see the doctor. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $10 
copayment for each PCP visit, including telehealth services.  
 
You have been asked to pay a $10 copayment for the telehealth visit. The telehealth visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 a primary care (PCP) telehealth visit provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99153) provided January 6, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were 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 99153 is not supported in the medical record. Specifically, this code has a professional 
component / technical component of 3. This service is not eligible for separate payment in the hospital setting. 
The service was billed with a place of service of 22 (outpatient hospital). 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 (99153) provided January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided September 9, 2021 to 
September 10, 2021. 
 
You asked the Plan to pay for the hospital services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were 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 the hospital services are not supported in the medical record. Specifically, the documentation 
shows that multiple medical visits were provided on the same day with the same revenue code without 
condition code G0 and procedure without modifier 25. This means this service is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of the hospital services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital services provided September 9, 
2021 to September 10, 2021.