Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you were told this was a valid code. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service April 28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography, abdomen and pelvis; without contrast material 
in one or both body regions, followed by contrast material(s) and further sections in one or both body regions 
(code 74178) provided on October 16, 2020. 
 
You asked the Plan to pay for the CT scan of the abdomen and pelvis with and without contrast. You say that 
the CT scan of the abdomen and pelvis was medically necessary. The Plan denied your request. The Plan says 
that the CT scan of the abdomen and pelvis was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pay for the CT scan of the abdomen and pelvis with 
and without contrast. Our reviewer says that the CT scan of the abdomen and pelvis with and without contrast 
was medically necessary. Our physician reviewer found the notes from October 2020 revealed a history of 
painless hematuria. The report of October 16, 2020 lists hematuria as the reason for the exam. The history of 
painless hematuria is a valid indication for CT of the abdomen and pelvis as listed in the CT report. 
 
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 CT scan of the abdomen and pelvis with and without contrast have been 
met. Therefore, we decided that the Plan has to pay for a computed tomography, abdomen and pelvis; without 
contrast material in one or both body regions, followed by contrast material(s) and further sections in one or 
both body regions (code 74178) provided on October 16, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022, billed with 
codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 
0032U, 0033U, 81407, 81406, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says only one code should be submitted for the panel testing. 
 
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 January 31, 2022, billed with codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81355, 81335, 81401, 0031U, 0032U, 0033U, 81407, 81406, 81238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is founded on 
30 years of basic science research linking Modic changes to chronic low back pain. You say that it is the only 
objective biomarker when treating patients with complaints of low back pain. You say that the Intracept 
procedure is safe, efficacious, durable, and reproducible for appropriately selected patients, like the enrollee. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic vertebrogenic low back pain have not been demonstrated in the peer-reviewed literature. 
The Plan says that more research is needed to show safety and efficacy of the procedure. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee scooter (i.e., a crutch substitute) coded as E0118 
you rented from March 28, 2022, to May 17, 2022. 
 
You asked the Plan to pay for the knee scooter. You say that you are unable to use crutches due to a previous 
wrist surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that knee scooters and other crutch substitutes are not 
covered for any indication. Therefore, we decided that the Plan does not have to pay for the knee scooter (i.e., a 
crutch substitute) coded as E0118 you rented from March 28, 2022, to May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) and anti-reflective coating per 
lens (V2750) provided on June 4, 2022. 
 
  You asked the Plan to pay for progressive lenses (V2781) and anti-reflective coating per lens (V2750). You say 
that you are appealing the second pair of glasses. The Plan denied your request. The Plan says the service is a 
covered benefit, but the enrollee has exceeded the limit set in the subscriber agreement. The Plan also says that 
on May 19, 2022, they made a payment in the amount of $110 toward glasses purchased on May 12, 2022, 
from the same provider, exhausting your eye wear benefit for the Plan 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 covers one pair of standard lenses and frames every year. 
 
We looked at the file and the Plan's rules. The Plan contract says they only cover one pair of glasses each year. 
The record shows that you purchased a pair of glasses on May 12, 2022. Therefore, your benefit has been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of progressive lenses 
(V2781) and anti-reflective coating per lens (V2750) have not been met. Therefore, we decided that the Plan 
does not have to pay for progressive lenses (V2781) and anti-reflective coating per lens (V2750) provided on 
June 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77067-26 billed for date of service July 9, 2021. 
 
You asked the Plan to pay for code 77067-26. You say that the patient had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 31, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 77067-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 77067-26 billed for date of service July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 19, 2022, billed 
with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, 
81407, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says only one code should be submitted for the panel testing. 
 
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 19, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81328, 81335, 81355, 81407, 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of 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 the lab services provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 27, 
2022, to March 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was warranted because 
the patient was considered to be at risk for serious adverse outcomes requirement a high level of hospital 
management. The Plan denied your request. The Plan says this admission did not meet medical necessity 
criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient presented to the emergency department on March 27, 2022, after a 
syncopal spell and facial trauma from the fall. Their temperature was 102.7, pulse was 123, blood pressure was 
135/80, respiration 19, and pulse oximetry was 99%. Facial imaging showed no fractures, chest x-ray showed 
no disease, and respiratory testing was positive for influenza A. He was admitted for oral antivirals, cardiology 
consultation and infectious disease consultation. He was discharged on March 28, 2022. The record does not 
show that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. The patient 
had a normal chest x-ray and normal oxygenation. Care could have been safely provided in the outpatient 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 27, 2022, to March 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on October 26, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office 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 an office visit (99213) provided on October 26, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 11, 2021. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite (D2392) provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 12, 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 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the record shows that the 
specimens were not collected on the billed date of service. 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 laboratory services rendered on April 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that Monovisc is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Synvisc is required before alternatives can be considered. 
 
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 Monovisc. Our reviewer says that 
Monovisc is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective for this 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device (K0553) 
provided July 20, 2021. 
 
You asked the Plan to pay for the CGM and supplies. You say that please find the attached records in order to 
process the claim. The Plan denied your request. The Plan says the enrollee does not meet the medically 
necessary criteria.  
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, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553) provided July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Continuous positive airway pressure (CPAP) 
device. 
 
You asked the Plan to reimburse you for the CPAP device. You say that you were told to provide a detailed 
invoice and evidence of your payment. Due to your insomnia, you sleep for a couple of hours and then wake 
up. The Plan denied your request. The Plan says the enrollee was not in compliance with CPAP usage 
requirements. The machine was not returned after 36 months. 
 
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 reimburse you for the CPAP device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the CPAP 
device at issue in this case meets all of Medicare's LCD criteria for medically reasonable and necessary for the 
enrollee. Provided medical records do not document use of the CPAP device for 4 or more hours per night on 
70% of nights during a consecutive thirty (30) day period as required by Medicare's LCD. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to reimburse you for Continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injections. You say that the services provided to the enrollee was out of 
medical necessity. The Plan denied your request. The Plan says the rendering provider is an OON provider 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 injections provided on June 17, 2022, by an 
out-of-network (OON) provider.