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

 
We decided that the Plan does not have to pay for procedure code 99233 provided on September 15, 16, 17, 
and 18, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233 provided on September 15, 16, 17, and 18, 2022. The Plan denied your request. The Plan says the 
medical records do not support the billing of code 99233 provided on September 15, 16, 17, and 18, 2022. 
 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, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99233. Our reviewer says that the medical 
records do not support the billing of code 99233 provided on September 15, 16, 17, and 18, 2022. Our reviewer 
found based on the documentation provided, the interval histories are not detailed. The medical decision 
making is limited and does not show high complexity. As such, the billing of CPT 99233 on September 15, 16, 
17, and 18, 2022, is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on September 15, 16, 17, and 18, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 You asked the Plan to pre-approve Xgeva. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Xgeva. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 2, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 8-14 drug classes (G0481) 
provided on August 8, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 8-14 drug classes. You say that this test was 
medically necessary. The Plan denied your request. The Plan says this test was not billed with the appropriate 
code. 
 
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 G0481 is the definitive drug testing of 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, we verified that more than 
14 classes of drugs were tested. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing of 8-14 drug classes have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing of 8-14 drug classes (G0481) provided on August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 19, 2022, to 
March 7, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you submitted all of the 
documentation necessary to pay this claim. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 20, 2022. The NOA was not received by the Plan until October 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 19, 2022, to March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from December 2, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says the initial 
claim submission must be received (according to the Julian Date) within 365 days from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient services was not filed until January 19, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient services provided from December 2, 2021, to 
December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) comprehensive 
genomic profiling test provided on July 15, 2021. 
 
You asked the Plan to pay for the F1Heme test. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the F1Heme test was not filed until November 23, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) comprehensive genomic 
profiling test provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on October 31, 2022. 
 
You asked the Plan to pay for the 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. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, an inpatient place of service 
code (21) was billed for a patient that was registered as an outpatient. Based on this information, we decided 
that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital care (99222) provided on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 7, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) received on November 3, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that this should be covered. The Plan denied your 
request. The Plan says the service at issue is not a covered benefit when performed during a medical eye 
examination. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service when it is performed as part of a routine screening. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) received on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 9, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 
received services from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on January 6, 2023. 
 
You asked the Plan to pay for the wellness visit. You say that you were with your previous primary care 
physician (PCP) for 17 years. You also say that you thought it was time to see a new PCP. The Plan denied 
your request. The Plan says the provider in this case was not your primary care physician on this date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
The record shows that you contacted the Plan to change your primary care physician (PCP) on January 10, 
2023. The Evidence of Coverage clearly states that upon requesting a change in your PCP, the request will not 
be effective until the first day of the month following the date of the request. The record shows that the date of 
service at issue in this case was before the call to change your PCP was made. Therefore, we decided that the 
Plan does not have to pay for the annual wellness visit provided on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx test provided on July 1, 
2021. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx test. You say that this test was medically 
necessary. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the FoundationOne Liquid CDx test was not filed until November 23, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx test provided on 
July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominal panniculectomy. 
 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as you have 
developed a rash and have been using over the counter remedies for treatment. The Plan denied your request. 
The Plan says there is no supporting documentation of chronic intertrigo, difficulty walking, or limitations 
affecting activities of daily living. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation does not support that the enrollee in this case has such complicating 
factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo 
dermatitis. The procedure would not be considered reconstructive. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve abdominal panniculectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 18, 2022, 
through September 2, 2022, and billed with diagnosis code E43-Unspecified severe protein-calorie 
malnutrition. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis E43 is supported by the records. The Plan denied your request. The Plan says the 
documentation does not support secondary diagnosis of E43. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code E43-Unspecified severe 
protein-calorie malnutrition. 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 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis of E43-Unspecified severe protein-calorie malnutrition. Our physician reviewer found 
while the member has lost weight, the member was previously obese. The member's body mass index was 31 
(BMI) and is now only mildly overweight with a body mass index of 26.6 (BMI). There is no evidence that the 
member has had changes to their hair, skin, or nails. There is no evidence that the member is retaining 
fluid.  As such, the billing of E43 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 18, 2022, through September 2, 2022, and billed with 
diagnosis code E43-Unspecified severe protein-calorie malnutrition.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 8, 2022, through 
June 14, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.9-Sepsis, unspecified. 
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 hospital services at the DRG 
originally billed. Our reviewer says that the documentation does not support the primary diagnosis of A41.9-
Sepsis, unspecified. Our physician reviewer found the member presented with syncope. The member 
subsequently developed a transient fever and transient leukocytosis. There was no definitive source of an 
infection. There is no evidence of hemodynamic instability or organ dysfunction secondary to and infection. 
The billing of A41.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 8, 2022, through June 14, 2022, and billed with diagnosis code 
A41.9.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $40 more for the bifocal lenses (V2200), polycarbonate or equal lenses 
(V2784), anti-reflective coating (V2750), and tint (V2744) purchased on January 13, 2023. 
 
You asked the Plan to pay $40 more for the bifocal lenses, polycarbonate or equal lenses, anti-reflective 
coating, and tint. You say that you overpaid $40 and would like to be reimbursed. The Plan denied your 
request. The Plan says that this claim was paid correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses once per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the record only shows that the Plan paid $60 toward this 
purchase. You have a $100 benefit to be used each year. Write-offs and disallowed amounts are not benefits 
that are actually paid by the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the bifocal lenses, polycarbonate or equal lenses, anti-reflective coating, and tint have been met. Therefore, we 
decided that the Plan has to pay $40 more for the bifocal lenses (V2200), polycarbonate or equal lenses 
(V2784), anti-reflective coating (V2750), and tint (V2744) purchased on January 13, 2023.  
 
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.