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

 
We decided that the Plan does not have to pay for lab services (81404, 81479) provided August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services billed are not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed are not covered for cardiovascular disease 
screening. These tests were initiated by the lab and not ordered by the enrollee's physician. 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 (81404, 81479) provided August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cochlear implant and related items (L8615, L8616, L8619, 
L8624) provided April 9, 2021. 
 
You asked the Plan to pay for the cochlear implant and related items. You say that these items were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. No itemized billing or shipping receipt was provided. 
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 cochlear implant and related items (L8615, 
L8616, L8619, L8624) provided April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 lab services provided on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex superion indirect decompression system for 
implantation of superion interspinous spacer (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex superion device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet 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 a Vertiflex superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental. More research is needed to determine 
long term safety and show efficacy compared with the gold standard treatment. 
 
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 Vertiflex superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex superion indirect decompression system for implantation of 
superion interspinous spacer (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 19, 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement provided to the 
enrollee on November 18, 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 CPT Code 77002 was billed without an appropriate primary code per Medicare guidelines and 
therefore is not eligible for payment. 
 
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 the 
services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for fluoroscopic guidance for needle placement provided to the enrollee on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction services received on February 1, 2022. 
 
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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for eye exams for the purpose 
of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only. 
 
The services you asked the Plan to pay for are considered refraction. Therefore, we decided that the Plan does 
not have to pay for eye refraction services received on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to discharge to 
LTACH level of care, and is not clinically appropriate for a lower level of care. You say that the enrollee 
exceeds the defining criteria for a medically appropriate LTACH admission. The Plan denied your request. The 
Plan says it is not medically necessary to be in a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available. The enrollee can remain at the current acute care hospital until no acute services are required. The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on June 22, 2020. 
 
You asked the Plan to pay for code 80050. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided 
November 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the service in dispute. The Plan denied your request. The Plan says service does not meet coverage 
requirements. 
 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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the enrollee had Tempus 
Gene Panel testing billed with multiple CPT codes, including 81479 with a -59 modifier. This one code was 
submitted on its own on a separate claim form while the other codes were submitted on a different claim form, 
but on the same day. 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. Additionally, modifiers should not be 
used to report multiple codes when a single specimen is tested. This testing was done on a single blood/tissue 
specimen. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology 
procedure (81479) provided November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14301) and intravenous injection 
of agent (15860) provided on October 25, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer (14301) and intravenous injection of agent (15860). 
You say that the operative report supports 14301 and 15860. The Plan denied your request. The Plan says 
procedure codes 14301 and 15860 are inclusive to procedure code 19357. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 15860 is intravenous injection 
of agent (eg, fluorescein) to test vascular flow in flap or graft. 
  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 adjacent tissue transfer (14301) and intravenous injection 
of agent (15860). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found that the operative report describes an adjacent tissue transfer (14301) 
and breast reconstruction on left breast. An adjacent tissue transfer may be reported on the same day as a breast 
reconstruction procedure if the adjacent tissue transfer is performed at a different site unrelated to the breast 
reconstruction. In this case, CPT 14301 would be inclusive to CPT 19357, and would not be reported 
separately. In addition, the intravenous injection of agent to test vascular flow (15860) would be inclusive to 
the adjacent tissue transfer and breast reconstruction since it is in the same anatomical location. 
 
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 adjacent tissue transfer (14301) and intravenous injection of agent (15860) 
have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer 
(14301) and intravenous injection of agent (15860) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prolonged evaluation and management service before 
and/or after direct patient care; first hour (99358) provided on November 16, 2021. 
 
You asked the Plan to pay for code 99358. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 code billed has an OPPS payment status indicator of "N". This means while payable under 
OPPS, the payment is included in the packaged payment for other services. No other services were provided. 
This code is not payable as billed on an outpatient hospital type of bill. Based on this information, we decided 
that Medicare rules for coverage of code 99358 have not been met. Therefore, we decided that the Plan does 
not have to pay for the Prolonged evaluation and management service before and/or after direct patient care; 
first hour (99358) provided on November 16, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the complete cystectomy (51595) and prostatectomy (55840) provided 
on December 14, 2021. 
 
You asked the Plan to pay for the complete cystectomy and prostatectomy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the services 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. In this case, the CPT Code Manual definition of 
code 51595 is cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine 
anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes 
(51595). The CPT Code Manual definition of CPT code 55840 is prostatectomy, retropubic radical, with or 
without nerve sparing. 
 
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 complete cystectomy and prostatectomy. Our reviewer 
says that CPT codes 51595 and 55840 meet criteria for billing and reimbursement consideration. Our reviewer 
found the documentation supports that both procedures were performed. 
 
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 complete cystectomy and prostatectomy have been met. Therefore, we 
decided that the Plan has to pay for the complete cystectomy (51595) and prostatectomy (55840) provided on 
December 14, 2021.  
 
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 pay for the unlisted multianalyte assay with algorithmic analysis 
(81599) provided November 8, 2021 to December 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says this test is considered experimental 
and investigational. This propriety test is not verified by MolDX and there is no evidence that this test will add 
clinical value to beyond the appropriate standard of care. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted 
multianalyte assay with algorithmic analysis (81599) provided November 8, 2021 to December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says you do not perform blood glucose testing at least four times per day or use 
insulin with at least three daily injections. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mycophenolic acid (J7518), the Prednisone (J7512), the 
Tacrolimus (J7507), and the Pharmacy supply fee (Q0511 and Q0512) provided on June 10, 2021. 
 
You asked the Plan to pay for codes J7518, J7512, J7507, Q0511, and Q0512. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Mycophenolic acid (J7518), the 
Prednisone (J7512), the Tacrolimus (J7507), and the Pharmacy supply fee (Q0511 and Q0512) provided on 
June 10, 2021 have been met. Therefore, we decided that the Plan does not have to pay for the Mycophenolic 
acid (J7518), the Prednisone (J7512), the Tacrolimus (J7507), and the Pharmacy supply fee (Q0511 and 
Q0512) provided on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member cannot live 
by herself because she is a risk to herself. The Plan denied your request. The Plan says that the records received 
show that you are seeking placement without evidence of active, ongoing inpatient psychiatric treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or 
homicidal ideation noted and no auditory or visual hallucinations. This patient does not show any abnormal 
behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as she does not have dangerousness to self or others and were compliant with her treatment with 
encouragement. Our physician reviewer found that the enrollee's condition does not meet criteria for inpatient 
psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.