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

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 16, 2022 billed with codes 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 0033U.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that this is the only thing that works for you. The Plan 
denied your request. The Plan says the Plan requires a trial of Xeomin before it will approve Botox. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Botox. Our reviewer says that you do 
not meet the criteria for a step therapy exception for Botox. Our physician reviewer found you have not tried 
and failed the Plan's preferred drug of Xeomin. The record does not show that this drug would likely be less 
effective or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on March 14, 
2022. 
 
You asked the Plan to pay for the ambulance transportation services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
Medicare does not pay for ambulance services when the enrollee is not inpatient at a facility.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was inpatient at a facility 
from March 13, 2022, to March 17, 2022. This means that payment for this ambulance transport is considered 
part of the inpatient stay and is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the ambulance transportation services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance transportation services provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test to detect bacterial 
overgrowth (91065). 
 
You asked the Plan to pre-approve a breath hydrogen or methane test. You say that this test is medically 
necessary to evaluate the enrollee for possible small intestinal bacterial overgrowth. The Plan denied your 
request. The Plan says this test is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen tests for diagnosing 
small bowel bacterial overgrowth and measuring small bowel transit time are excluded from coverage.  
 
We looked at the file and Medicare rules. The test at issue is requested for a non-covered indication. Based on 
this information, we decided that Medicare rules for coverage of a breath hydrogen or methane test have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a breath hydrogen or methane test 
to detect bacterial overgrowth (91065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99213 provided on April 26, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this service is bundled as 
part of the global surgical fee for minor surgical procedure 37211 (transcatheter therapy, arterial infusion for 
thrombolysis other than coronary or intracranial, any method, including radiological supervision and 
interpretation, initial treatment day). This service was billed by the same provider. This means this code is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit 
coded 99213 provided on April 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says the requested PT sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve additional physical therapy provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
January 14, 2022. 
 
You asked the Plan to pay for the surgical pathology. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 88305 is level IV surgical pathology with gross and 
microscopic examination. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the documentation shows 
that there is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of the surgical pathology have not been met. Therefore, we decided 
that the Plan does not have to pay for the surgical pathology services coded 88305 provided on January 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 10, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says to receive 
payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a 
Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 at-home tests (A9270) with sales tax (S9999) 
provided on January 18, 2022. 
 
You asked the Plan to pay for COVID-19 at-home tests with sales tax. You say that the items at issue were a 
necessity for your care. The Plan denied your request. The Plan says the items are not a covered benefit on the 
date of service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has started a new initiative on April 4, 
2022, that will cover up to eight over-the-counter COVID-19 tests each calendar month. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of COVID-19 at-home tests with sales tax have not been met. Specifically, the date of service at issue 
is not an eligible date for the Medicare initiative. Additionally, Medicare does not reimburse separately for 
sales tax. Therefore, we decided that the Plan does not have to pay for COVID-19 at-home tests (A9270) with 
sales tax (S9999) provided on January 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still requires treatment and is not 
medically stable to go home yet. The Plan denied your request. The Plan says there is no clinical evidence to 
support the medical necessity for a continued SNF stay.  
  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 that as of October 22, 2022, the enrollee did not require any skilled nursing or rehab 
services on a daily basis. The enrollees function was at or near the new baseline and they can be discharged to 
a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before your hospitalization 
and want to return to being independent. You say that you are eager to participate in three hours of aggressive 
therapy that an IRF will offer you. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no complex functional deficits specified that would require intense 
therapy or interdisciplinary team management in an IRF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on February 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on January 17, 2022, to 
February 15, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted with the claims. 
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 home health services rendered on January 17, 
2022, to February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on January 4, 2022 without applying 
a deductible. 
 
You asked the Plan to pay for x-ray services without applying a deductible. You say that this provider is the 
only portable x-ray supplier working for the nursing home. The Plan denied your request. The Plan says 
member has to meet a deductible of $750.00 before plan will pay for services rendered. The member resides at 
the nursing facility and is not at the facility under an approved SNF admission; there is no authorization 
approving the admission. 
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. The enrollees contract with the Plan says that there is a $750 deductible. 
 
We looked at the file, the Plans rules and Medicare rules. The file shows that the x-ray services were not 
authorized and the enrollees Plan says there is a $750 deductible. Therefore, we decided that the Plan does not 
have to pay for x-ray services provided on January 4, 2022 without applying a deductible.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554) provided on October 11, 2021. 
 
You asked the Plan to pay for a CGM and supplies. You say that medical records have been submitted for 
services. The Plan denied your request. The Plan says they have insufficient documentation to corroborate 
services and confirm Medicare coverage has been met. 
 
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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The records do not show that there is a relationship with the 
enrollee. The records also show that the last two office visits on 6/8/2021, and 9/17/2021, were with a different 
provider and not the provider who wrote the physician order. Therefore, we decided that the Plan does not have 
to pay for a therapeutic continuous glucose monitor (CGM) and supplies (K0553, K0554) provided on October 
11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from skilled nursing as a part of 
your plan of care. You say that your doctor indicated you would need an additional six weeks due to the 
location of your injury and you would be unable to take care of the injury by yourself. The Plan denied your 
request. The Plan says you do not require skilled services at the SNF. 
  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 or skilled therapy needs. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs can 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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on January 15, 
2022. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that you disagree with the denial, 
and you want the Plan to pay for the service. The Plan denied your request. The Plan says members must pay 
all costs to return to their service area. 
 
Medicare rules say that services provided outside of the US are not covered. The Plan follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of non-emergency ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for non-emergency ambulance services provided on January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 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 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, a comprehensive genetic panel, 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 rendered on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis, 
Nodify CDT test (81599) provided February 18, 2022. 
 
You asked the Plan to pay for the Nodify CDT test. You say that the enrollee was diagnosed with a Pulmonary 
Nodule (PN) and the Nodify CDT blood-based test was ordered to determine whether this PN was high risk for 
malignancy prior to performing an invasive biopsy or surgery. The Plan denied your request. The Plan says the 
Nodify CDT test is not approved by the FDA. The Nodify CDT test is not considered a clinically validated test 
for evaluation of solitary pulmonary nodules. 
 
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 Nodify CDT test have not been met. Therefore, we decided that the Plan does not have to pay 
for the unlisted multianalyte assay with algorithmic analysis, Nodify CDT test (81599) provided February 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99212 and 99213 provided on December 
14, 2021, to December 31, 2021. 
 
You asked the Plan to pay for procedure codes 99212 and 99213. 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 as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. CPT codes 99212 and 99213 have a status indicator of "B" and are 
not recognized by OPPS when submitted on an outpatient hospital Part B bill type 13X. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99212 and 99213 provided on December 14, 2021, to 
December 31, 2021.