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

 
We decided that the Plan does not have to pay for EsoGuard testing (0114U) provided on July 26, 2023. 
 
You asked the Plan to pay for EsoGuard testing. You say that the service at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says this molecular pathology testing is not a covered 
benefit. 
 
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 DEXTM Diagnostics Exchange does not show that the 
test at issue is covered under the MolDX program. Based on this information, we decided that Medicare rules 
for coverage of EsoGuard testing have not been met. Therefore, we decided that the Plan does not have to pay 
for EsoGuard testing (0114U) provided on July 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27062 rendered on September 6, 2023. 
 
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 procedure code 27062-59-LT is considered inclusive to CPT 27130-LT. 
 
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 27062 is "Excision; trochanteric bursa or calcification." 
 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that excision of trochanteric bursa is 
included in the code for total hip surgery, and should not be billed separately. 
 
We looked at this coder'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 procedure code 27062 rendered on September 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement and the home visit evaluation provided 
on March 30, 2023. 
 
You asked the Plan to pay for the nail debridement and the home visit evaluation. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nail debridement and 
the home visit evaluation provided on March 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
July 03, 2023, to July 28, 2023. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you disagree with 
the copayment. 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 a $40 
copayment for cardiac rehabilitation services. 
 
You have been asked to pay a $40 copayment for cardiac rehabilitation services. This item/service falls within 
the cardiac rehabilitation services 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. The total amount you owe is $240 ($40 x 6 visits = $240). Therefore, we 
decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on July 
03, 2023, to July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service June 26, 2023. 
 You asked the Plan to pay for the billed testing. You say that the critical value of the testing benefits the 
enrollee. The Plan denied your request. The Plan says an appropriate code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the panel testing billed for date of service June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 26, 2023, billed with 
codes 81227, 81231, 81232, 81306, 81328, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's 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 
June 26, 2023, billed with codes 81227, 81231, 81232, 81306, 81328, and 81335.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad billed for dates of service May 
3, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical literature shows the efficacy of the 
treatment. The Plan denied your request. The Plan says the device is not reasonable or necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. We find that the provided fluid circulating cold pad with pump 
(Code E0218) is not considered medically reasonable or necessary. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the fluid circulating cold pad billed for dates of service May 3, 2023, to May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
June 20, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copayment. 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 a $250 
copayment for outpatient hospital services/surgery services. 
 
You have been asked to pay a $250 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/surgery services 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 outpatient hospital services provided on June 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 3, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was billed with valid diagnoses. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R0902 has an Excludes1 note in relation to J80. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 07, 2023. 
 
You asked the Plan to pay for the lab testing. You say that requesting reconsideration stating that obtaining a 
result from this type of testing is key to optimizing and planning treatments, improving patient outcomes and 
minimizing unnecessary or inappropriate therapies and procedures. The Plan denied your request. The Plan 
says that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the lab testing provided 
on July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 28, 
2023. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. 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 a $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on July 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 38724, 21011, 42415, 70491, 88305, 88311, G1004, 
J0131, J0330, J0690, J1100, J1170, J2370, J2405, J2404, J3010, J3475, J3490, J7120, and Q9967 for date of 
service June 28, 2023. 
 You asked the Plan to pay for codes 38724, 21011, 42415, 70491, 88305, 88311, G1004, J0131, J0330, J0690, 
J1100, J1170, J2370, J2405, J2404, J3010, J3475, J3490, J7120, and Q9967. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 codes 38724, 21011, 42415, 70491, 88305, 88311, G1004, J0131, J0330, J0690, J1100, 
J1170, J2370, J2405, J2404, J3010, J3475, J3490, J7120, and Q9967 are not payable as billed. Specifically, 
code 38724 is an inpatient only procedure. In addition, the remaining services were billed on the same date of 
service as the inpatient procedure and are therefore, not separately payable as billed. Based on this information, 
we decided that Medicare rules for coverage of codes 38724, 21011, 42415, 70491, 88305, 88311, G1004, 
J0131, J0330, J0690, J1100, J1170, J2370, J2405, J2404, J3010, J3475, J3490, J7120, and Q9967 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 38724, 21011, 42415, 70491, 
88305, 88311, G1004, J0131, J0330, J0690, J1100, J1170, J2370, J2405, J2404, J3010, J3475, J3490, J7120, 
and Q9967 for date of service June 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services provided from July 10, 2023, to 
July 16, 2023. 
 
You asked the Plan to pre-approve the home health services. You say that you believe these services were 
billed correctly. The Plan denied your request. The Plan says you billed this claim with an incorrect Type of 
Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). Based on this rule, you should have billed this claim with Type of Bill code 0329 or 0327.  Instead, you billed 
this claim with code 0323, which is incorrect. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve home health services provided from July 10, 2023, to July 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the acupuncture on July 14, 2023. 
 
You asked the Plan to waive the deductible for the acupuncture. You say that you were not aware of the 
deductible at the time of service. 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. Your 
contract with the Plan says that there is a $950 deductible which applies to acupuncture for chronic low back 
pain.  
 
The item or service you asked the Plan to waive the deductible for falls within the acupuncture for chronic low 
back pain benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $950 deductible which applies to acupuncture for chronic low back pain. This cost sharing is a 
contractual obligation that had not been met at the time the acupuncture was received on July 14, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the acupuncture on July 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Restasis.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary angiography with catheter placement 
procedure. 
 
You asked the Plan to pre-approve coronary angiography with catheter placement procedure. You say that the 
requested coronary angiography with catheter placement procedure is medically necessary. The Plan denied 
your request. The Plan says the requested coronary angiography with catheter placement procedure is 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 coronary angiography with catheter 
placement procedure. Our reviewer says that the requested coronary angiography with catheter placement 
procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient had a negative radionuclide stress test in July 2023. Guidelines do not support a need for invasive 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered 
medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of coronary angiography with catheter placement procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve coronary angiography with catheter 
placement procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that you need a stair glide to get up and down your 
stairs. You said that you have fallen on your stairs several times.  The Plan denied your request. The Plan says 
this item is not covered under your Medicare benefits. The Plan covers all items that Medicare covers. 
Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LOKELMA. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 LOKELMA.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Briumvi. 
 You asked the Plan to pre-approve Briumvi. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drug.  
 
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 Briumvi. Our physician reviewer found 
that the enrollee has multiple sclerosis. The Plan requires a trial of Ocrevus before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation 
provided indicating that the Plans required drug 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 Briumvi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Briumvi.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 10, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on January 10, 2023.