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

 
We decided that the Plan does not have to pay for an office or other outpatient visit (code 99214) provided on 
November 28, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office or other outpatient visit (code 99214) provided on 
November 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical classification was not documented. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of venous insufficiency, chronic and peripheral, with chronic 
idiopathic venous hypertension, with ulcer of right lower extremity. The enrollee's medical history includes 
systemic sclerosis, scleroderma, Raynaud's disease, hand amputation, and below-knee amputation. The 
physical exam was notable for severe chronic venous stasis changes with significant wounds of the right medial 
malleolus and anterior foot. An ultrasound showed that the saphenous vein gave off varicosities in the calf 
which coursed down to the right foot. However, the case file does not contain documentation of the CEAP 
clinical classification and the revised Venous Clinical Severity Score. The documentation does not support that 
the coverage criteria have been met in this case. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous therapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on February 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that there was no other procedure performed on this date 
of service. The Plan denied your request. The Plan says that this charge is incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide documentation to support what or if 
another service was provided on the same date of service and if it was paid. Therefore, we decided that the Plan 
has to pay for the office visit provided on February 22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve submucosal radiofrequency ablation of the tongue base 
for the treatment of obstructive sleep apnea. 
 
You asked the Plan to pre-approve submucosal radiofrequency ablation of the tongue base for the treatment of 
obstructive sleep apnea. You say that this procedure is medically necessary for this patient's condition and is 
preferable to other treatment options. The Plan denied your request. The Plan says submucosal radiofrequency 
ablation of the tongue base for the treatment of obstructive sleep apnea is considered 
experimental/investigational and is non-covered. 
 
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 submucosal radiofrequency ablation of 
the tongue base for the treatment of obstructive sleep apnea. 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 a diagnosis of Obstructive sleep apnea. Continuous positive airway pressure (CPAP) has 
been prescribed, but the enrollee is unable to use it due to claustrophobia. There is insufficient support in the 
medical literature for the use of submucosal ablation of the base of the tongue in the management of 
obstructive sleep apnea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of submucosal radiofrequency ablation of the tongue base for the treatment of 
obstructive sleep apnea have not been met. Therefore, we decided that the Plan does not have to pre-approve 
submucosal radiofrequency ablation of the tongue base for the treatment of obstructive sleep apnea.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC genetic testing panel provided on 
October 13, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC genetic testing panel. You say that this test was approved 
via a Novitas LCD and should be covered. The Plan denied your request. The Plan says a unique identifier was 
not reported as required. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test was reviewed by the MolDX contractor and assigned a 
unique identifier that is reported on the claim. However, this test is listed as not covered by Medicare in the 
DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the 
DecisionDx-SCC genetic testing panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the DecisionDx-SCC genetic testing panel provided on October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective angiography codes 72726-59 and 75774-59 
provided on November 23, 2022. 
 
You asked the Plan to pay for 72726-59 and 75774-59. You say that the enrollee had multiple exams on this 
date. The Plan denied your request. The Plan says these codes are inclusive to other billed codes and the use of 
the -59 modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not support that these were distinct, separate procedural services. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for selective angiography codes 72726-59 
and 75774-59 provided on November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs this device. The Plan 
denied your request. The Plan says the requested ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found the enrolle's arterial blood gas (ABG) showed severe acute on chronic hypercarbic respiratory failure. The documentation 
indicates the enrollee improved with bilevel positive airway pressure (BiPAP) and diuresis. The reviewer found 
the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD) is listed in the record, but 
pulmonary function testing in 2020 indicated severe restrictive lung disease, without obstruction. The clinical 
notes indicate that COPD is not responsible for the enrollees carbon dioxide (CO2) retention. There is no ABG 
done while stable to confirm chronic CO2 retention. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. Therefore, the reviewer found that the requested home ventilator is 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation evaluation and management (EM) services 
provided on May 27, 2021, billed with code 99220. 
 
You asked the Plan to pay for the EM services as billed. You say that it is felt that this was coded correctly. 
The Plan denied your request. The Plan says the services rendered do not meet the definition of code 99220. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the records do not support the EM code billed in this case. Our reviewer found the enrollee is a female with 
a pacemaker and an ejection fraction of 20-25% based on last echocardiogram who was seen in the hospital for 
nausea, weakness, and tiring easily with walking. She reported no vomiting. Workup revealed a brain 
natriuretic peptide (BNP) of 2476, normal troponin levels, and a normal chest x-ray. She was given Zofran for 
nausea and intravenous furosemide.  
 
The provided documentation only revealed a focused history and examination, not a comprehensive history and 
physical examination, and the decision making was not of high complexity, as the enrollee had known heart 
failure, acute coronary syndrome was ruled out, and she was medically stable. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the observation evaluation and management (EM) services provided on May 27, 
2021, billed with code 99220.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 25, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406 
and 81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical records. 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 
July 25, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406 and 81437.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual physical exam you had on December 5, 2022. 
 
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says you have exceeded the 
benefit limit. 
 
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 there is a $0 
copayment for one annual physical exam per calendar year.  
 
Review of the file show that you had a physical exam on December 5, 2022. The records also show that you 
had a covered physical exam on April 26, 2022. The Plan covers only one physical exam per calendar year. As 
such, the requested services exceed the benefit limit and are not covered. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not 
have to pay for the annual physical exam you had on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new socket for a prosthetic leg from an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a new socket for a prosthetic leg from an OON provider. You say that there 
is no other provider in network who can supply the item needed. You say that the requested OON provider has 
been your provider for the past several years. The Plan denied your request. The Plan says there are network 
providers who are able to supply the items needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 new socket for a prosthetic leg from 
an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found you have standard prosthetic needs that may reasonably be met with in network 
providers. You do not require continuity from your previous provider. You are not receiving active treatment 
nor is a treatment routine being interrupted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a new socket for a prosthetic leg from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on February 3, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, the claim was not billed with 
a valid primary diagnosis code (J12.82). Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have 
to pay for subsequent hospital care (99233) provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services rendered on February 3, 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 we reimburse anesthesia codes to anesthesia providers only. 
 
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 states that they reimburse anesthesia codes to anesthesia providers 
only. The Medicare rules say that payment for anesthesia can be made to a certified registered nurse anesthetist 
(CRNA). The file shows that the rendering provider is a CRNA per the National Provider Identifier (NPI) 
registry. The Plan has not provided any documentation or binding Medicare rules to support that the services 
are not payable as billed. Therefore, we decided that the Plan has to pay for the anesthesia services rendered on 
February 3, 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 pay for SelectMDx genetic testing (0339U) provided on November 
4, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says this test has not met the coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pay for SelectMDx genetic testing (0339U) provided on November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 12, 2022, billed with 
codes 81162, 81403, 81404, 81405, 81406, 81407, 81408, 81479, 81201, 81292, 81295, 81298, 81307, 81317, 
81321 and 81351. 
 
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 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 
August 12, 2022, billed with codes 81162, 81403, 81404, 81405, 81406, 81407, 81408, 81479, 81201, 81292, 
81295, 81298, 81307, 81317, 81321 and 81351.