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

 
We decided that the Plan does not have to pay for the genetic testing provided on October 10, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that you are asking for reconsideration of genetic 
testing that was performed. You were not aware that genetic testing was being done. Please reconsider the 
denial of genetic testing. The Plan denied your request. The Plan says prior authorization is needed for genetic 
testing. 
 
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 genetic testing provided on October 10, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service November 
21, 2022. 
 You asked the Plan to pay for procedure code 99214. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99214 is bundled into payment for code 90832. 
 
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 99214 
is a column II code to column I code 90832. 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 99214 billed for date of service November 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Breast Cancer Index test (81518) provided on July 29, 
2022. 
 
You asked the Plan to pay for the Breast Cancer Index. You say that this test is supported in the medical record. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 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. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the Breast Cancer 
Index have not been met. Therefore, we decided that the Plan does not have to pay for the Breast Cancer Index 
test (81518) provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
September 26, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation service billed with code 99243 for date of 
service November 23, 2022. 
 
You asked the Plan to pay for the consultation service. You say that you believe this is a payable code. The 
Plan denied your request. The Plan says you billed a consultation code that is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare ceased recognizing Current Procedural 
Terminology (CPT) consultation codes for payment effective for services furnished on or after January 1, 2010. 
The code you billed is a consultation code and is therefore not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the consultation service have not been met. Therefore, we decided that the Plan does not have to 
pay for the consultation service billed with code 99243 for date of service November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radial keratotomy provided on December 1, 2022. 
 
You asked the Plan to pay for the vision service. You say that you preferred the laser surgery due to the better 
outcomes and shorter recovery times. You say that you were advised by Plan representatives that you would 
only be responsible for a $375 copayment. You also say that the Plan should honor what you were told by the 
plan representatives. The Plan denied your request. The Plan says the service is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of radial keratotomy and/or keratoplasty 
for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or 
contact lenses, which are specifically excluded.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vision service have not been met. Therefore, we decided that the Plan does not have to pay for 
the radial keratotomy provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on October 30, 2022. 
 
You asked the Plan to pay for the physician services. 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 99223 is not supported in the medical record. Specifically, the claim was billed with an 
inpatient place of service (21) however records show that the enrollee was an outpatient. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99223) provided on October 
30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test/type 3 porta (G0399). 
 You asked the Plan to pre-approve a home sleep test. 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. 
 
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered when 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 home sleep test. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the home sleep test/type 3 porta at issue in this case meets all Medicare 
criteria for medically reasonable and necessary for the enrollee. Provided records in this case do not document 
a face-to-face clinical evaluation by the treating physician which includes a sleep history and symptoms 
including, but not limited to, snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, 
morning headaches; and, an Epworth Sleepiness Scale; and, a physical examination that documents body mass 
index, neck circumference and a focused cardiopulmonary and upper airway system evaluation. 
 
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 sleep test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep test/type 3 porta (G0399).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9367 billed for date of service May 20, 
2022, to May 26, 2022. 
 
You asked the Plan to pay for procedure code S9367. You say that these claims should be processed as in-
network. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9367 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9367 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9367 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9367 billed for date of service May 20, 2022, to May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from October 2, 2022, to 
October 6, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed with the correct DRG based on the medical records. The Plan denied your request. The Plan 
says the medical record does not support the DRG originally billed. 
 
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 diagnosis code A41.9, Sepsis, unspecified 
organism. 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 medical records to not support the DRG originally billed. Our 
physician reviewer found that in this case, there was no clinical or laboratory evidence of sepsis. The review 
has determined that the documentation did not support A41.9, Sepsis, unspecified organism. 
 
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 from October 2, 2022, to October 6, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 ventilator is medically necessary. The 
Plan denied your request. The Plan says the records do not show compliance data within the last 12 months. 
The request 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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) which 
could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up 
rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. In 
fact, records note improvement with BiPAP treatment in the hospital setting. As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2022, billed 
with codes 81335, 81227, 81401, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
December 13, 2022, billed with codes 81335, 81227, 81401, and 81291.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator (SCS) implant trial. 
 
You asked the Plan to pre-approve a SCS implant 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 implant trial. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the request is medically reasonable and 
necessary. The referring physician is an Orthopedic surgeon. 
 
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 implant trial have been met. Therefore, we decided that the Plan has to 
pre-approve a spinal cord stimulator (SCS) implant 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from April 8, 
2022, to May 7, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. 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 April 8, 2022. The NOA was not received by the Plan until June 7, 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 billed for dates of 
service from April 8, 2022, to May 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery services coded as 76000, 28310 and 
28289, provided July 19, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that you had been told that the provider was no 
longer participating so you assumed that it would be out of network. You would not have had the surgery with 
this provider had you been aware. The Plan denied your request. The Plan says the services was rendered 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 the 
outpatient surgery services coded as 76000, 28310 and 28289, provided July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80048, 83550, 84153) 
provided on September 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that this provider has requested in-network 
participation. The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 laboratory services (36415, 80048, 83550, 
84153) provided on September 29, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trabecular bone score (TBS) dual energy 
X-Ray absorptiometry (DEXA) scan. 
 
You asked the Plan to waive the copayment for TBS DEXA scan. You say that you were not informed that this 
would be performed along with your routine testing. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for in-network TBS DEXA.  
 
You have been asked to pay $30, which is less than the $50 copayment for TBS DEXA scan. This item/service falls within the Outpatient Diagnostic Testing and Therapeutic Services and Supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a trabecular bone score (TBS) dual energy X-Ray 
absorptiometry (DEXA) scan.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care provided on August 3, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the service should be covered. The Plan denied 
your request. The Plan says that the service is not covered. 
 
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, review of the file shows that the Plan did not provide enough 
information to substantiate their denial. Therefore, we decided that the Plan has to pay for the subsequent 
hospital care provided on August 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.