Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on 
September 29, 2021, and February 16, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you were told these visits 
would be covered. The Plan denied your request. The Plan says the copayments applied are 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 
 You have been asked to pay a total of $90 copayment for the specialist office visits. Specialist office visits fall 
within the Physician/Practitioner services, including doctors office visits 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 copayments for specialist office visits provided on September 29, 2021, and 
February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging of the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET scan with concurrently acquired CT. You say that you recommend 
this PET scan be approved for the enrollee so that he may have this prior to his next visit. The Plan denied your 
request. The Plan says this request cannot be approved because it is not supported for the first staging of 
prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pre-approve a PET scan with concurrently acquired 
CT. Our reviewer says that a PET scan is not medically necessary. Our physician reviewer found the patient 
already has sufficient information to suspect stage IV prostate cancer and if clarification is needed, an MRI 
could be a safer, reasonable imaging choice. There was insufficient support made in the provider's statements 
and documentation justifying this test at this time. Our reviewer also found that therefore, this request for a 
PET scan will be considered not medically 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 PET scan with concurrently acquired CT have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging of the 
skull base to mid-thigh (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted supplies and materials used in non-surgical 
procedures (99070) provided December 22, 2021. 
 
You asked the Plan to pay for the unlisted supplies. You say that this paper is all you have left to send. It is the 
approval of the services requested, sent to you from the Plan. The Plan denied your request. The Plan says an 
itemized bill was requested but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of unlisted supplies and materials used in 
non-surgical procedures (99070) provided December 22, 2021. have been met. An itemized bill was requested 
in order to continue processing for payment. The Plan made multiple attempts to obtain the additional 
information from the provider without success. Therefore, we decided that the Plan does not have to pay for 
unlisted supplies and materials used in non-surgical procedures (99070) provided December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on December 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. 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 FANCC genetic testing provided on 
December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain. The Intracept procedure is experimental. 
More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 8, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14021) provided on August 9, 
2021. 
 
You asked the Plan to pay for the adjacent tissue transfer (14021). You say that these codes can be billed with a 
modifer per CCI edit. You say that the medical records should be reviewed and CPT codes 14021 and 97605 
processed. The Plan denied your request. The Plan says procedure code 97605 has been overturned. The Plan 
also says procedure code 14021 remains denied as there is a more appropriate procedure code for the service 
performed. 
 
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 14021 is adjacent tissue transfer or rearrangement, scalp, 
arms and/or legs; defect 10.1 sq cm to 30.0 sq cm. 
 
 
  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 adjacent tissue transfer (14021). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report does not include documentation of adjacent tissue transfer or rearrangement of scalp, arms, or 
legs. The documentation supports services were performed on neck. Therefore, this procedure code cannot be 
verified. 
 
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 adjacent tissue transfer (14021) have not been met. Therefore, we decided 
that the Plan does not have to pay for the adjacent tissue transfer (14021) provided on August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transversus abdominis plane (TAP) block coded 64488 
and the ultrasonic guidance for needle placement coded 76942 provided on September 13, 2021. 
 You asked the Plan to pay for the transversus abdominis plane (TAP) block and the ultrasonic guidance for 
needle placement. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services billed are 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 CPT code. In this case, we have confirmed that code 64488 
is a column II code to column I code 00832. We have confirmed that code 76942 is a column II code to column 
I code 64488. 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 the transversus abdominis plane (TAP) block coded 64488 and the ultrasonic guidance for needle 
placement coded 76942 provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Veristrat testing (81538) provided on November 29, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81538 is non-covered.  
 
We looked at the file and Medicare rules. Per LCD L35000, code 81538 is not covered. 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 Veristrat testing (81538) provided on November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the billed services are not supported in the medical record. Specifically, the interpretation services 
were not billed with the appropriate modifier for separate payment to be made. 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 the services provided on March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on February 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 hospital services provided on February 24, 2022, 
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 tetanus and diphtheria vaccine provided on October 11, 
2021. 
 
You asked the Plan to pay for the tetanus and diphtheria vaccine. You say that the doctor suggested you have a 
tetanus shot during a wellness exam. You say that you are immunocompromised, and it was imperative to 
receive this shot. The Plan denied your request. The Plan says this vaccine is covered under Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus and 
diphtheria vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus and 
diphtheria vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus and diphtheria 
vaccine provided on October 11, 2021.  
 
  Benefits for the tetanus and diphtheria vaccine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing services coded as 81206 and 
81292 provided February 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the Tempus Gene Panel was ordered by an 
in-network provider. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD Criteria, 
and Diagnosis code does not substantiate service. 
 
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 81206 is BCR/ABL1 (T(9;22)) (eg, chronic myelogenous 
leukemia) translocation analysis; major breakpoint, qualitative or quantitative  and 81292 is MLH1 (mutl 
homolog 1, colon cancer, nonpolyposis type 2). 
 
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 laboratory services. Our reviewer says that the Medicare 
criteria for coverage was not met. Our reviewer found that CPT 81206 was reported with ICD 10 C34.12 
Malignant neoplasm of upper lobe, left bronchus, or lung. In this case, diagnosis code does not support service 
billed. CPT 81292 was reported with ICD 10 C34.12 Malignant neoplasm of upper lobe, left bronchus, or lung.  
In this case, diagnosis code does not support service. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for molecular pathology testing services coded as 81206 and 81292 provided February 23, 
2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital admission and care provided from October 
27, 2021, to November 9, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 inpatient care. Our reviewer says that the 
inpatient readmission was medically necessary. Our physician reviewer found the provided documentation 
indicates that the readmission was medically necessary. The reviewer found that though the enrollee was 
appropriately discharged safely from the previous admission, a separate crisis developed. Therefore, the 
reviewer found that the requested readmission was 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 inpatient care have been met. Therefore, we decided that the Plan has to pay 
for the acute inpatient hospital admission and care provided from October 27, 2021, to November 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular monitoring services provided on February 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for cardiovascular monitoring services. You say that  The Plan denied your request. 
The Plan says the services were provided out-of-network and were not approved in advance. 
 
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 cardiovascular monitoring services provided on 
February 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 20, 
2021, through October 24, 2021. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the acute inpatient hospital 
care provided was not medically necessary. 
 
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 the 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 that the enrollee presented to the Emergency department as he had fever, 
lethargy, and diarrhea for several days. The diarrhea was treated with loperamide at home and was resolved but 
his fever persisted. He was noted as alert and oriented but tired. He was later admitted with a diagnosed urinary 
tract infection (UTI), sepsis, and metabolic encephalopathy. He had a foley catheter replaced without 
complication, and was treated with IV antibiotics. His blood pressure increased and the enrollee remained alert 
and oriented with stable organ function. There were no signs of sepsis or other condition that might justify an 
inpatient admission. The enrollee could have tolerated treatment and monitoring at a lower level of care. At the 
time of admission, there was no suggestion that the enrollee would have required hospital services that would 
likely have crossed two midnights. 
 
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 October 20, 2021, through 
October 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the admission was medically necessary. The 
Plan denied your request. The Plan says the SNF admission is not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that 
the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.