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

 
We decided that the Plan does not have to pay for pharmacogenomic testing (81479) provided August 9, 2021. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that this test was 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 GeneSight testing may only be ordered by 
licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for 
patients diagnosed with major depressive disorder (MDD). 
 
We looked at the file and Medicare rules. The record does not show that this service was ordered by a licensed 
psychiatrist or neuropsychiatrist. Based on this information, we decided that Medicare rules for coverage of the 
pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
pharmacogenomic testing (81479) provided August 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health physical and occupational therapy provided 
from April 17, 2021, through April 30, 2021. 
 
You asked the Plan to pay for home health physical and occupational therapy. The Plan denied your request. 
The Plan says the additional information requested was not provided to review for payment reconsideration due 
to lack of medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for home health 
physical and occupational therapy provided from April 17, 2021, through April 30, 2021.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the medical services coded 95938, 95957, 95908, 95937, 95887, and 
95885. We decided that the Plan does not have to pay for continuous intraoperative neurophysiology 
monitoring (G0453).  
 
You asked the Plan to pay for the medical services coded 95938, 95957, 95908, 95937, 95887, and 95885. You 
say that you would like this claim reprocessed based on the medical documentation. The Plan says that this 
claim has denied correctly. 
 
We decided that the Plan has to pay for the medical services coded 95938, 95957, 95908, 95937, 95887, 
and 95885.  
 
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 indicated that these codes are not appealable. There 
is no argument given for why these codes are not appealable. We have no indication the Plan has made a 
reasonable and diligent request to review these services for payment. Therefore, we decided that the Plan has to 
pay for the medical services coded 95938, 95957, 95908, 95937, 95887, and 95885.  
 
We also decided that the Plan does not have to pay for continuous intraoperative neurophysiology 
monitoring (G0453). 
 
The Plan follows 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 G0453 is a column II code to column I code 95957. 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 continuous 
intraoperative neurophysiology monitoring (G0453). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound coded 76705 provided on October 
15, 2021. 
 You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound coded 76705 provided on October 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0650) provided August 24, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the item billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show that the ordering physician discussed the need for the item with the 
enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided  
August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (83789, G0480, 80307) provided on October 12, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the referring physician is a contracted provider and has 
received reimbursement for his/her services. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and 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 record shows that the referring 
provider is also 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 drug testing (83789, G0480, 80307) provided on October 12, 2021, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this is not a covered 
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 Gemtesa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurology consultations to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the neurology consultations. You say that you would like reconsideration 
because the requested provider is the only specialist available to treat your condition. The Plan denied your 
request. The Plan says there are in-network providers available who may render your necessary care. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 neurology consultations. Our reviewer says that you have a 
neuromuscular disorder/syndrome. Your network contains multiple neurologists with subspecialty certification 
in neuromuscular disorders who could provide adequate care. Our physician reviewer found there was no indication that all such services have been exhausted to date. Furthermore, the health plan also has in network 
physiatrists who can assist in your care and rehabilitation needs.  An out-of-network waiver would otherwise 
exceed your clinical needs and cannot be determined to be 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 neurology consultations have not been met.  
 
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 the neurology consultations. Therefore, we decided 
that the Plan does not have to pre-approve the neurology consultations to be provided by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 4, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic services coded A9570 provided on May 7, 
2021. 
 You asked the Plan to pay for the diagnostic services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
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 A9570 
is a column II code to column I code 78800. 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 diagnostic services coded A9570 provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (64415) provided September 30, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is 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. 
 
We find that CPT code 64415 is not supported in the medical record. Specifically, the code billed is included in 
CPT 01630 which was also billed. Based on this information, we decided that Medicare rules for coverage of 
the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (64415) provided September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim is a duplicate. 
 
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 CPT codes 84443, 80076, 84100 and 80048 are not supported in the medical record. Specifically, 
the denied services appear to be a duplicate of the same services billed on the same date of service. 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 laboratory services provided to the enrollee on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 71045 is a column II code to column I code 71046. 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 imaging services provided to the enrollee on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (G0467, 99213) provided October 5, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were 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. 
 
We find that CPT code G0467, & 99213 is not supported in the medical record. Specifically, the claim did not 
include a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage 
of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office 
visit (G0467, 99213) provided October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you in full for transportation services provided on  
July 29, 2021. 
 
You asked the Plan to reimburse you in full for the transportation services. You say that you needed 
transportation to your cataract surgery and back home after surgery. The Plan denied your request. The Plan 
says you were reimbursed for the out-of-network non-authorized transportation services $130.00 as a one- 
time exception courtesy. The total charges were $193.00. The allowed amount was $150.00. The member was 
reimbursed $130.00 leaving a $10 copayment per trip. The $30 gratuity and $13.50 service fees are not 
reimbursable as they are non-covered services. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the transportation 
destination was not Plan-approved. Therefore, we decided that the Plan does not have to reimburse you in full 
for transportation services provided on July 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided 
September 23, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services were 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 rules state that evaluation and management by 
psychologists is covered by Medicare when the provider consults the attending or primary care physician about 
the services furnished. 
 
 
 
 
 We looked at the file and Medicare rules. The record does not show that the provider attempted to consult with 
the primary care or attending physician. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services (90834) provided September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy. Your rehab needs can be met safely 
at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract removal services (66984-55-RT) provided on 
September 13, 2021. 
 
You asked the Plan to pay for code 66984-55-RT. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that the physician providing the remaining postoperative 
care must show the date care was assumed in Item 19 on the paper Form CMS-1500. 
 
We looked at the file and Medicare rules. The provider must document the dates the care was assumed and 
relinquished in the line item 19 field on the paper Form CMS-1500; however, this is not documented on the 
CMS-1500 claim form as required. 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 cataract 
removal services (66984-55-RT) provided on September 13, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the necessary services can be provided at a lower level of care. 
 
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 has not provided any medical records for your appeal request. Without 
medical records we are unable to substantiate the Plans denial rationale. Therefore, we decided that the Plan 
has to pre-approve skilled nursing facility (SNF) services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a modifier was not billed on the claim to represent the services as separate/distinct. 
 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 71045 
is a column II code to column I code 71046. 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 radiology services provided to the enrollee on October 19, 2021.