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

 
We decided that the Plan does not have to pay for BRCA1, BRCA2 (breast cancer 1 and 2) genetic testing 
(81162) provided December 22, 2021. 
 You asked the Plan to pay for the genetic testing. You say that you are a laboratory and do not have direct 
access to patient charts. The ordering provider confirms the test is medically necessary and is informed of the 
risks, benefits and alternatives before authorizing this service. The Plan denied your request. The Plan says the 
records do not support that this was medically reasonable and necessary. 
 
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 the genetic testing have been met. The 
records show that the Plan made multiple attempts to obtain the relevant additional supporting clinical records 
from the provider without success. Therefore, we decided that the Plan does not have to pay for BRCA1, 
BRCA2 (breast cancer 1 and 2) genetic testing (81162) provided December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99140 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (procedure code G0483) rendered on 
November 22, 2022.  
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 number of definitive urine drug classes requested 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 pay for 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 review has determined that he enrollee did not need 22 or more drug classes tested 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive drug testing (procedure code G0483) rendered on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous injection, bebtelovimab, includes injection 
and post administration monitoring in the home by an out-of-network provider. 
 
You asked the Plan to pay for the intravenous injection, bebtelovimab, includes injection and post 
administration monitoring in the home. You say that your doctor ordered the services. The Plan denied your 
request. The Plan says this provider does not participate with Medicare. 
 
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 intravenous injection, bebtelovimab, includes injection and 
post administration monitoring in the home by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 28, 2021, and 
September 30, 2021. 
 
You asked the Plan to pay for the physician's services. You say that the claims were filed timely. The Plan 
denied your request. The Plan says the claim was beyond 12 months of the date of service and denied for 
timely filing submission. 
 
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 physician's services was not filed until January 18, 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 physician's services provided on September 28, 2021, and 
September 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 SCS trial. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the use of spinal cord stimulation in Complex 
Regional pain Syndrome is evidence-based therapy. It is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SCS trial have been met. Therefore, we decided that the Plan has to pre-
approve a spinal cord stimulator (SCS) trial.  
 
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 pre-approve chimeric antigen receptor T-cell (CAR-T) therapy 
(0540T). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CAR T-cell therapy with Brexucabtagene autoleuce ifl is Food and Drug Administration (FDA) 
approved for the treatment of relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) in 
adults. Coverage criteria stipulates no prior CAR T-cell therapy. This enrollee had CAR T-cell therapy in 2020. This approach remains investigational. The service is not reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chimeric antigen receptor T-cell (CAR-T) therapy (0540T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC genetic testing (0315U) provided 
November 17, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDX-SCC test was 
denied in error and you are requesting it to be reprocessed and paid. The DecisionDX-SCC test is a covered 
Medicare benefit. The Plan denied your request. The Plan says this test is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Per the Plans Medical Policy, Proprietary Laboratory Analyses (PLA) 
codes, code 0315U is listed under PLA codes that are noncovered due to experimental/investigational status. 
Medicare rules say that items and services that are not medically necessary are not covered.   
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the DecisionDX-SCC genetic testing (0315U) provided November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87471, 87500, 87551) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the lab services. 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 a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (87481, 87471, 87500, 87551) 
provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Minuteman Interspinous device. 
 
You asked the Plan to pre-approve implantation of the Minuteman Interspinous device. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implantation of the Minuteman 
Interspinous device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the minuteman device is experimental for 
back pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the Minuteman Interspinous device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve implantation of the Minuteman Interspinous 
device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service October 23, 
2022. 
 You asked the Plan to pay for procedure code 99284. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99284 is bundled into 
payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service October 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an elliptical machine purchased on October 14, 
2022. 
 
You asked the Plan to reimburse you for an elliptical machine. You say that you want the Plan to reimburse 
you for this item. The Plan denied your request. The Plan says this item is not considered to be durable medical 
equipment and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
   
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to reimburse you for an elliptical machine purchased on October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid panel (80061) provided December 21, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you get this service completed yearly and 
this is the first time you have had any responsibility. The Plan denied your request. The Plan says the benefit 
maximum for this time period has been reached. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, is covered once every 5 years. The Plan had previously paid procedure code 
80061 for date of service December 2, 2021. A lipid panel was provided less than 5 years prior to the visit at 
issue in this case. Therefore, we decided that the Plan does not have to pay for lipid panel (80061) provided 
December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an 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 magnetic resonance imaging (MRI) shows disc herniations and stenosis. The 
cause of the back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary, rest home visit (99337) debridement of 
mycotic nails (11721) provided on December 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary, rest home visit. You say that please review the attached medical 
records proving medical necessity and reprocess this claim for payment. The enrollee is in an assisted living 
facility. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 the domiciliary, rest home visit (99337) 
debridement of mycotic nails (11721) provided on December 1, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an 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 only reports 6/10 pain levels and does not have a recent 612-week trial 
of physical therapy for back pain. There is no disease progression on the repeat magnetic resonance imaging 
(MRI). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 you are currently stable and require rehabilitation to 
start the recovery process. The Plan denied your request. The Plan says ongoing skilled care can be provided in 
an alternate setting. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a dental appliance for sleep apnea purchased on 
October 19, 2022. 
 
You asked the Plan to reimburse you for a dental appliance for sleep apnea. You say that this should be 
covered. The Plan denied your request. The Plan says they did not receive any medical records to support the 
need for the oral sleep apnea device. 
 
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 a dental appliance for sleep apnea have 
been met. There are no medical records within the casefile. Without the requested clinical information, we are 
unable to determine if the requested services are medically necessary. Therefore, we decided that the Plan does 
not have to reimburse you for a dental appliance for sleep apnea purchased on October 19, 2022.