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

 
We decided that the Plan does not have to pay for the laboratory services provided on December 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was based on the diagnosis 
provided by the ordering physician. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 
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 the laboratory services provided on December 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81210, 81275) provided October 
29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was 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 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, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. 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 (81206, 81235, 81210, 81275) provided October 
29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88112, 88305, 88312, 88361) 
provided on December 27, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the services in this case have not been 
billed with an appropriate modifier as required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. In this case, these services were not billed with the required modifier 
to indicate that you are requesting payment for only the professional component of the rendered services. Based 
on this information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services (88112, 88305, 88312, 
88361) provided on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 21, 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 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis rendered on December 21, 2021. 
 
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 detailed written order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the elbow orthosis rendered on 
December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the enrollee may need physical and/or occupational therapy, there is no documented need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81210, 81235, 81275, 81404, 
81405, and 81479 provided on September 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
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 codes 81210, 81235, 81275, 81404, 81405, and 81479 are not supported in the medical 
record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code 
must be submitted for the panel. Review of the file does not support that only one code was submitted for the 
panel. 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 the laboratory services coded 81210, 
81235, 81275, 81404, 81405, and 81479 provided on September 2, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Gelsyn-3. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 22, 2021. 
 
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 cardiovascular risk assessment screening, 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 July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) device 
for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this modality for chronic pain management is still being studied to see if this treatment 
is as good or better than standard treatment for chronic pain. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this modality for chronic pain management is still being studied to see if this treatment is as good or 
better than standard treatment for chronic pain. Thus far, there is insufficient medical literature to support the 
use of the SPRINT PNS system for chronic knee pain. Although it is Food and Drug Administration (FDA) 
approved, it is still under review for an indication for use in chronic pain management of knee osteoarthritis 
and is considered experimental/ investigational for this indication. Therefore, 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the SPRINT peripheral nerve stimulator (PNS) device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 10, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test results were needed to help determine 
the course of treatment for this enrollee. The Plan denied your request. The Plan says the testing is not 
medically necessary. 
 
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. The rules say that the testing is unlikely to impact therapeutic 
decision making. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home Covid-19 tests provided on February 8, 2022. 
 
You asked the Plan to pay for the provided testing. You say that group health plans are required to cover the 
cost of at-home tests. The Plan denied your request. The Plan says Medicare only provides coverage and 
payment starting April 4, 2022. 
 
The Plan must follow Medicare rules. The Centers for Medicare and Medicaid services say that starting April 
4, 2022, and continuing until the COVID-19 public health emergency (PHE) ends, people with Medicare Part B 
can get up to eight free over-the-counter tests for the month of April any time before April 30, and can then get 
another set of eight free over-the-counter tests during each subsequent calendar month through the end of the 
COVID-19 PHE. Medicare will not provide payment for over-the-counter COVID-19 tests obtained prior to 
April 4, 2022.  Therefore, we decided that the Plan does not have to pay for the at-home Covid-19 tests 
provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 10-kHz High-Frequency spinal cord stimulation (SCS) 
trial. 
 
You asked the Plan to pre-approve a 10-kHz High-Frequency SCS 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 all of the 
conditions 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 10-kHz High-Frequency SCS trial. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
literature supporting a change of SCS that is functional for a new unit. 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 10-kHz High-Frequency SCS trial have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a 10-kHz High-Frequency spinal cord stimulation (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2025) provided November 21, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says only one pair of eyeglasses can be covered per year. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provides up to $200 towards one pair of eyeglasses per calendar year. 
 
We looked at the file and the Plan's rules. The Plan provides up to $200 towards one pair of eyeglasses per 
calendar year. 
The plan paid $189.98 towards one pair of glasses. No benefit is provided for a second pair. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglasses (V2025) provided November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 20, 2021 by 
an out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 the chiropractic services provided on December 
20, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services (procedure code 76376) provided to the enrollee on 
January 12, 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 that this procedure exceeds the maximum number of services allowed under the guidelines for a 
single date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a clear rationale for why multiple exams on this date 
service was inappropriate. The plan did not specify what guidelines were used for their decision. Therefore, we 
decided that the Plan has to pay for imaging services (procedure code 76376) provided to the enrollee on 
January 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional screening services provided to the enrollee on 
January 25, 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 the records submitted do not indicate that two separate services were performed or 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 the denied codes is: 
 
CPT 77063: 
 
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) 
 
CPT 77067: 
 
Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
when performed 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the enrollee had a unilateral screening 
exam on 1/25/22. Instead of properly coding for screening digital mammogram - CPT 77063 and 
tomosynthesis CPT 77067 in the same report as recommended in the CPT manual, the radiology authored a 
separate report for each of the two codes. This does not properly constitute two separate exams. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional screening services provided to the enrollee on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided 
December 22, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the item billed.  
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for 
a continuous glucose monitor (K0553, K0554) provided December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gene panel provided on January 18, 2022. 
 
You asked the Plan to pre-approve the testing services. You say that the testing was necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says the testing is not a 
Medicare benefit. 
 
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. The FoundationOne gene panel provided includes the FANCC gene. 
Panels of tests that include this gene is statutorily excluded from service. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the gene panel provided on January 18, 2022.