Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device rendered on June 20, 
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 must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The services at issue are a PCD described by code E0675. These 
services are denied by Medicare. Therefore, we decided that the Plan does not have to pay for the pneumatic 
compression device rendered on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had three heart surgeries in three weeks, and you 
were informed that rehab may be needed. The Plan denied your request. The Plan says based on Medicare 
guidelines, 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home modification ramp for wheelchair access 
(S5165). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you need this wheelchair ramp for your 
power wheelchair. The Plan denied your request. The Plan says the wheelchair ramp is not covered because it 
is not medical in nature and is regularly and primarily used by persons who do not have a specific medical need 
for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a home modification ramp for wheelchair access (S5165).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 21, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99233 is bundled into payment for code 36589. 
 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 99233 
is a column II code to column I code 36589. 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 99233 billed for date of service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on May 12, 
2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are 
non-covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on May 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (87631) provided on February 14, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that there is a more 
appropriate code for these services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services (87631) 
provided on February 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing coded as 81270, 81219, 81338, 
81279, 81240 and 81241. 
 
You asked the Plan to pre-approve the genetic testing. You say that say the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the coverage criteria for 
the requested testing have not been met and cannot be considered reasonable and necessary. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee has thrombophilia and anemia in the 
setting of a history of deep venous thrombosis and pulmonary embolism.  The record provided does not 
indicate that the enrollee is BCR-Abl negative.  The rule states that it is a non-coverage policy for genetic 
testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A 
(G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate 
reductase enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, 
including cardiovascular risk assessment, are non-covered except for pregnant patients. The elements of the 
coverage criteria are not satisfied, and the requested service is not recommended. 
 
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 the genetic testing coded as 81270, 81219, 81338, 81279, 81240 and 81241.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the records do not show that it is medically necessary 
to be in an LTACH in place of an acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are having issues with the 
oxygen tank giving you enough air to make it to appointments, you need a portable oxygen concentrator. The 
Plan denied your request. The Plan says they do not cover duplicate or redundant durable medical equipment 
such as oxygen device when the second item performs the same function as the one currently provided to the 
enrollee. There is no medical documentation to support your need for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary concentrator and a Homefill unit with D-tanks for portability. These 
units serve the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone tablets. 
 
You asked the Plan to pre-approve Prednisone tablets. The Plan denied your request. The Plan says Prednisone 
is an oral, self-administered drug and is not covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone tablets.  
 
Benefits for Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you experienced a lot of pain and need to 
be admitted. The Plan denied your request. The Plan says admission to an LTACH is not to be used as an 
alternative to completion of the full course of treatment at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on June 1, 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 claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 ambulance 
transport rendered on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the evaluation and management service. You say that the waiting list for a 
consultation with network providers is one-year long. You also say that you are due for a colonoscopy soon. 
The Plan denied your request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, bte (V5261) provided April 
28, 2022, by an out of network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you spoke to a Plan representative and was quoted 
that the enrollee had hearing aid benefits and CPT does not need prior authorization. The Plan denied your 
request. The Plan says enrollees must receive their hearing services from an in-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by an in-network provider.  
 
We looked at this physician's review, the file, and the Plan's rules. 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.  Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aid, digital, binaural, bte (V5261) provided April 28, 
2022, by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on June 8, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on June 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 24, 2022. 
 
You asked the Plan to pay for physical therapy. You say that your services are outpatient, so this code modifier 
is appropriate. The Plan denied your request. The Plan says the use of revenue code 0410 in combination with 
modifier -GP is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that physical therapy services using modifier -GP 
must be billed in combination with revenue code 42x.  
 
We looked at the file and Medicare rules. This service was billed with revenue code 0410, representing 
respiratory therapy, and modifier -GP, which is not a valid combination of revenue code and modifier. 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 pay for physical therapy provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 14, 2022. 
 You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. Also, panel testing should be billed using one CPT code 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. The rules also 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. 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. In addition, this was an NGS 
panel that was not billed with a single panel code as required. Therefore, we decided that the Plan does not 
have to pay for lab services provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
January 31, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the billed codes are 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (U0003, U0005) provided on September 
23, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says this claim needs to be submitted to the enrollee's primary 
insurance and an explanation of benefits from this carrier needs to be submitted for secondary payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for laboratory services (U0003, U0005) provided on September 23, 2021.