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

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2022, and billed 
with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335, and 81355. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 
21, 2022, and billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335, 
and 81355.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve twelve additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says that it appears that current formal therapy should meet clinical expectations 
with the now total 24 approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says 
that the requested additional visits are medically reasonable and necessary. Our physician reviewer found that 
the clinical documentation is showing that there is still a requirement for assistance with assistive device trials. 
This would require the professional skill of a therapist. In addition, not all of the documentation physical 
therapy goals have been met. The goals appear to be appropriate; thus, twelve additional sessions are medically 
reasonable and 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 additional visits have been met. Therefore, we decided that the Plan has to 
pre-approve twelve additional physical therapy visits for the enrollee.  
 
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 laboratory services provided on March 16, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on March 16, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit and x-ray provided on May 26, 
2021. 
 
You asked the Plan to waive the deductible for office visit and x-ray. You say that this should be covered. The 
Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies and Physician/Practitioner Services, Including Doctor's Office Visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies and Physician/Practitioner Services, Including 
Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$750 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies and 
Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation 
that had not been met at the time office visit and x-ray was received on May 26, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for office visit and x-ray provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exploratory laparotomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the computed tomography showed a small 
Bochadalek hernia on the left side. The Plan denied your request. The Plan says the documentation does not 
support thyroid biopsy as 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the available medical records are insufficient to demonstrate that an exploratory laparotomy is 
medically reasonable and necessary for the enrollee in this case. The physical examination and imaging study 
do not identify a condition for which the requested surgery is indicated. The case file does not contain 
documentation of serious or long-term significant abdominal symptoms for which the procedure is medically 
reasonable and 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an exploratory laparotomy for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care (99308) billed for date of service 
January 11, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you have provided medical records 
to support the services at issue. The Plan denied your request. The Plan says that rules for payment have not 
been met because the services at issue are included in another billed code. 
 
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. Specifically, the Plan has denied this service stating that payment for CPT code 
99308 is included in the payment of CPT code 99309. The Plan has not forwarded any evidence that CPT code 
99309 was billed on the same date of service. The Plan has not provided additional evidence to indicate why 
CPT code 99308 cannot be paid. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plans denial is not substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for subsequent nursing facility care (99308) billed for date of service January 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that this device is 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 powered upper extremity orthosis. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested device is not known to be effective, based on scientific 
evidence, professional standards, and expert opinion, in improving health outcomes in stroke patients. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be separately payable. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the Intracept procedure is still considered 
investigational and therefore 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 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. Our physician 
reviewer found this is considered an experimental/investigational procedure. 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 Intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation of the basivertebral nerve (Intracept procedure).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wearable home defibrillator provided on 
February 18, 2022. 
 
You asked the Plan to waive the coinsurance for a wearable home defibrillator. You say that you were only 
able to wear this item for two weeks and do not believe you should have to pay so much. The Plan denied your 
request. The Plan says the coinsurance applied was correct. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$3080.95 resulting in a coinsurance amount of $616.19 (3080.95 x 20% = $616.19). 
 
You have been asked to pay a $616.19 coinsurance for a wearable home defibrillator. A wearable home 
defibrillator falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the coinsurance for a wearable home defibrillator 
provided on February 18, 2022.  
 
Your complaint about not being able to tolerate this item is not a valid appeal for medical coverage. The plan 
has stated that they cannot pro-rate charges of this nature. This part of your complaint is a grievance that must 
be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiological services provided to the enrollee on 
March 11, 2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 . Our reviewer says that the services at issue in this case were 
not supported by the medical records. Our reviewer found that in this case, intraoperative neuromonitoring 
services were provided. The records did not support performance of 95907 as no nerve conduction testing was 
done. Testing of pedicle screws is considered to be triggered electromyography (EMG) (and falls within the 
EMG CPT codes). There was no evidence that a standard nerve conduction study (NCS) was performed or 
provided. As no NCS was performed, the use of CPT code 95886 would not have been appropriate. The use of 
another CPT code would be correct coding. In terms of CPT 95937, formal neuromuscular junction testing was 
not done in this case. This would not reflect the appropriate use of this CPT code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for 
neurophysiological services provided to the enrollee on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97140 billed for date of service February 28, 
2022. 
 You asked the Plan to pay for procedure code 97140. You say that this code should be separately payable. The 
Plan denied your request. The Plan says payment for code 97140 is bundled into payment for code 29581. You 
did not bill with a -59 modifier which may have permitted separate payment. 
 
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 97140 
is a column II code to column I code 29581. 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 97140 billed for date of service February 28, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the available medical records do not support 
necessity of the service as defined by Medicare 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support the criteria for inpatient hospital care. Our physician 
reviewer found there is no documentation that the admitting physician reasonably expected that your necessary 
hospital care would span two midnights. The expected length of hospital stay is not mentioned in any of the 
available medical records. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery 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 experimental and investigational procedures are not covered by Medicare. 
 
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 that this device is experimental. More research is needed. 
 
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 Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on February 4, 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 that the testing is not covered. 
 
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 references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on February 4, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health substance abuse rehabilitation. 
 
You asked the Plan to pre-approve behavioral health substance abuse rehabilitation. You say that the requested 
rehabilitation is medically necessary. The Plan denied your request. The Plan says medical necessity not met; 
clinical information furnished does not substantiate the need for requested units at residential treatment level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 behavioral health substance abuse 
rehabilitation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has shown no mood instability, thoughts of harming himself or others. There is no documentation of 
withdrawal or abnormal vital signs. There is no documentation of the enrollee needing 24-hour treatment. He 
did not have any delusions or hallucinations and did not have any auditory or visual hallucinations. Based on 
review the records provided, the enrollee does not meet the criteria for treatment at a residential level of care 
and could be treated at a lesser restrictive environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health substance abuse rehabilitation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve behavioral health substance abuse rehabilitation.