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

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 
81335, 81355, 81407 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting reconsideration of the 
denied charges for payment and is seeking review. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 
February 9, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81238, 
81291, 81306, 81328, 81335, 81355, 81407 and 81479.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 16, 2021. 
 
You asked the Plan to pay for the medical services. You say that you do not believe that the patient was 
completely enrolled in hospice. The Plan denied your request. The Plan says either Original Medicare or 
hospice is responsible for this bill.  The Medicare database confirms that this patient was enrolled in hospice on 
the date of service. 
 
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 medical services provided on May 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation (Low Complexity) (97161) 
provided February 8, 2022 to March 3, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that the therapy sessions provided through 
urgent care was necessary in order to deal with the remaining scar tissue left behind from your lipedema 
surgery last year. This therapy was recommended by the surgeon to help you deal with the residual pain from 
the surgery. The Plan denied your request. The Plan says the Plan does not cover care performed outside of the 
United States unless it is an emergency. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the physical therapy evaluation (Low Complexity) (97161) provided February 8, 2022 to March 3, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve WATS 3D Histocytology (88361, 88104, 88312, 88305) provided 
November 3, 2021. 
 
You asked the Plan to pre-approve the WATS 3D Histocytology. You say that this service was medically 
necessary. The Plan denied your request. The Plan says that coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 WATS 3D Histocytology. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the American Society of Gastrointestinal Endoscopy suggests using WATS-3D in 
patients with known or suspected Barrett's esophagus in addition to white light endoscopy. 
 
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 WATS 3D Histocytology have been met. Therefore, we decided that the 
Plan has to pre-approve WATS 3D Histocytology (88361, 88104, 88312, 88305) provided November 3, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 30, 2022. 
 You asked the Plan to pay for the orthosis. You say that the records provided support the necessity of the 
services. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific clinical rationale for the requested lumbar-sacral orthosis (L0650). The 
review has determined that the medical records provided did not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent inpatient hospital care (99232) provided 
February 17, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that your physician provided medically necessary 
services to the enrollee in good faith. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition until the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on [ENTER DATE OF REVOCATION or TERMINATION]. 
The services in question were provided before the end of that month. Therefore, we decided that the Plan does 
not have to pay for the subsequent inpatient hospital care (99232) provided February 17, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant trial. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 a spinal cord stimulator implant trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
documentation of a psychological evaluation. At this time, however, 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 a spinal cord stimulator implant trial have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator implant trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel (81286, 
81413, 81414, 81442, 81161, 81479) provided November 24, 2021. 
 
You asked the Plan to pay for the cardiovascular screening/risk assessment panel. You say that the treatment 
sought by the enrollee is medically necessary. The Plan denied your request. The Plan says this service is not 
covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes 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 for cardiovascular risk testing are non-covered for 
screening purposes. Based on this information, we decided that Medicare rules for coverage of the 
cardiovascular screening/risk assessment panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the cardiovascular screening/risk assessment panel (81286, 81413, 81414, 81442, 81161, 
81479) provided November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
March 31, 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 exceed the supply allowance. 
 
The Plan must follow Medicare rules. The rules say that billing more than one (1) UOS per thirty (30) days of 
code K0553 or A4238 will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The file shows that code K0553 was billed more than once in a 30 
day period. 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 continuous glucose monitor (CGM) 
supplies rendered on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57267 billed for date of service June 24, 
2021. 
 
You asked the Plan to pay for procedure code 57267. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 57267 is bundled into 
payment for code 57425. 
 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 57267 
is a column II code to column I code 57425. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 57267 billed for date of service June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
January 24, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
 
 
 
 We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor (CGM) supplies rendered on 
January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 31, 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 procedure code 27524 is not supported. 
 
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 27524 is open treatment of patellar fracture, with internal 
fixation and/or partial or complete patellectomy and soft tissue repair. 
 
 
 
 
 
 
 
 We find that CPT code 27524 is not supported in the medical record. Specifically, there is no documentation of 
open treatment of patellar fracture with internal fixation and/or partial or complete patellectomy and soft tissue 
repair. 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 surgical services rendered on January 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0037U) provided March 2, 2022. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current medical guidelines from the National Comprehensive Cancer Network do not 
recommend genetic testing for the enrollee's condition in patients over 60 without metastases. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (0037U) provided March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (26125) provided January 20, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the services 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. 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 26125 is a partial palmar fasciectomy. 
 
We find that CPT code 26125 is not supported in the medical record. Specifically, the operative report provided 
does not provided enough information to determine that this service was performed. Based on this information, 
we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided 
that the Plan does not have to pay for surgical services (26125) provided January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair and lite rider you purchased on July 13, 2021, 
and October 4, 2021. 
 
You asked the Plan to pay for the lift chair and lite rider. You say that you purchased these items from the only 
place that had the equipment you needed. The Plan denied your request. The Plan says you used a provider that 
is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lift chair and lite rider you purchased 
on July 13, 2021, and October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient visit (code 99205) provided by a urologist on 
January 20, 2022. 
 
You asked the Plan to pay for the new patient visit (code 99205). You say that this claim was coded correctly. 
The Plan denied your request. The Plan says this code was not billed correctly because the patient had 
previously been seen by the same specialty within the same group. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to bill a new patient evaluation and 
management (E/M) code, the term new patient means a patient who has not received any professional 
services, from the physician or physician group practice (same physician specialty) within the previous 3 years. 
In this case, this patient had a new patient visit (also code 99205) provided by another urologist in the same 
group on date of service December 28, 2021.  This is within this 3-year time frame.  Because these two 
physicians are in the same practice and have the same specialty (urology), the visit on January 20, 2022, should 
not have been billed as a new patient visit. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the new patient visit (code 99205) have not been met. Therefore, we decided that the Plan does not 
have to pay for the new patient visit (code 99205) provided by a urologist on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to adjust the cost sharing for the eye exams with diagnostic imaging provided on 
March 17, 2022, and March 31, 2022. 
 
You asked the Plan to adjust the cost sharing for the eye exams with imaging. You say that you were asked to 
pay your $40 specialist copayment at the time of these appointments and do not understand why you are being 
told you owe $95 per visit. The Plan denied your request. The Plan says that the cost sharing was correctly 
applied, but the Plan was not able to perform a full review on the appeal. 
 
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 $50 
copayment for "services for the diagnosis and treatment of diseases and injuries of the eye". 
 
We looked at the file and Medicare rules. You presented on both dates at issue for services to diagnose/treat 
conditions of the eye. The Plan processed these claims to apply a $54.01 copayment for the exam and a $40.99 
copayment for the imaging. However, both codes as a whole would be considered to be services for the 
diagnosis and treatment of diseases and injuries of the eye. As such, you cannot be asked to pay more than $50 
for each of the two visits. Please note that though you argue that a $40 copayment should be applied, the 
language for a specialist copayment in your contract would allow for separate cost sharing to be applied for the 
imaging, whereas both the exam and imaging are covered by the $50 copayment per the contract language.  
Based on this information, we decided that Medicare rules for coverage of the eye exams with imaging have 
been met. Therefore, we decided that the Plan has to adjust the cost sharing for the eye exams with diagnostic 
imaging provided on March 17, 2022, and March 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99334) provided on December 16, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a rest home visit (99334) provided on December 
16, 2021 by an out-of-network (OON) provider.