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

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service November 9, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. In addition, codes 94761 and 99072 are 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. The rules also 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 procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 billed for date of service November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cancer genetics testing provided on December 22, 2022, 
and billed with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81345, 
and 81351. 
 
You asked the Plan to pay for the cancer genetics testing. You say that the treatment sought is medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the cancer genetics testing have not been met. Therefore, we decided that the Plan does not have to pay for the cancer genetics testing provided on 
December 22, 2022, and billed with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81345, and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 17, 2023, to 
February 28, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on January 17, 2023, to February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 26, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on March 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vagus nerve stimulation (ViviStim) (64568). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 service. Our physician reviewer 
found the enrollee does not have a diagnosis of medically refractory partial onset seizures for whom surgery is 
not recommended or for whom surgery has failed, nor does the enrollee have a diagnosis of treatment-resistant 
depression. The enrollee does not have a nationally non-covered indication for VNS. While vagus nerve 
stimulation paired with upper limb rehabilitation therapy has shown promise for improving upper limb function 
following stroke, there is insufficient evidence in the medical literature regarding longer-term outcomes and the 
comparative effectiveness for rehabilitation outcomes in patients with hemiparesis following stroke.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the vagus nerve stimulation (ViviStim) (64568).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 29, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that the services should be reimbursed. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient rehabilitation and is 
not being seen daily at the current facility and risks decline if they remain in this setting. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on February 18, 2023. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. 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 drug testing 
provided on February 18, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code J2704. We decided that the Plan does not have to pay 
for procedure code Q9967.  
 
You asked the Plan to pay for procedure codes Q9967 and J2704 billed for date of service August 11, 2022. 
You say that medical records were provided. The Plan says that the billed codes cannot be verified. 
 
 We decided that the Plan has to pay for procedure code J2704.  
 
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 injection, propofol, 10 mg. We find that 5 units of CPT 
code J2704 is supported in the medical record. Specifically, the anesthesia records do show that 50 milligrams 
of propofol was provided. Based on this information, we decided that Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for procedure code J2704 billed for date of service August 
11, 2022.  
 
We also decided that the Plan does not have to pay for procedure code Q9967. 
 
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 Q9967 is low osmolar contrast material, 300-399 mg/ml 
iodine concentration, per ml. We find that 5 units of CPT code Q9967 is not supported in the medical record. 
The records do show that Omnipaque contrast media was provided. However, the records do not indicate how 
much was provided or support the 5 units billed. 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 procedure code 
Q9967 billed for date of service August 11, 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.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for 0245U billed for date of service February 8, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the required 
unique identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The records show that the enrollee received a ThyGeNEXT test. We find that CPT code 0245U is supported. 
The applicable billing guideline does not require a unique identifier to be billed. Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for 0245U billed for date of service February 8, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99397 billed for date of service February 21, 
2023. 
 
You asked the Plan to pay for procedure code 99397. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
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 99397 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code 99397 is non-covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99397 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99397 billed for date of service February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service February 8, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. The Plan 
denied your request. The Plan says the claim was not billed with an appropriate diagnosis code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 87086 was billed with diagnosis code N32.3 The billed diagnosis code is not listed 
among those that support medical necessity. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87086 billed for date of service February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TissueCypher Barrett's esophagus assay provided on 
January 23, 2023. 
 
You asked the Plan to pay for theTissueCypher Barrett's esophagus assay. You say that the TissueCypher 
Barrett's esophagus assay was medically necessary. The Plan denied your request. The Plan says the requested 
TissueCypher Barrett's esophagus assay is unproven. 
 
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 TissueCypher Barrett's esophagus assay. Our reviewer says that the requested TissueCypher Barrett's esophagus assay is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has had mapping biopsies of 
long-segment Barrett's esophagus that confirmed no dysplasia by gold standard histological assessment. No 
information was presented for this review to characterize the enrollee has high risk. The enrollee is not a 
candidate for eradicative therapy based on specialty-society guidance criteria and the lack of dysplasia found 
on mapping biopsies. The medical necessity and appropriateness for TissueCypher is not supported by the 
clinical information provided.  
 
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 TissueCypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's esophagus assay provided on  
January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump billed with code 
E0217 for September 2, 2022, to September 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that if code E0215 or E0217 is provided it will be denied 
as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue is a water circulating heat pad with pump billed 
with code E0217. This item is denied by Medicare as not medically necessary. Therefore, we decided that the 
Plan does not have to pay for the water circulating heat pad with pump billed with code E0217 for September 
2, 2022, to September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 02, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on September 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. You say that the enrollee has a high pre-test probability 
for Obstructive Sleep Apnea and existing comorbidities of hypertension, dyslipidemia, and diabetes type II, 
requiring a supervised polysomnography study. The Plan denied your request. The Plan says the clinical 
information does not indicate that the enrollee has observed apneas (stopped breathing), choking or gasping 
during sleep, and a completed and abnormal score on the Epworth Sleepiness Scale. 
 
The Plan follows Medicare rules. Medicare rules say that for a diagnosis of OSA to be made, the criteria listed 
in the Medicare rules section of this letter must be 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 polysomnography. Our reviewer says 
that an attended diagnostic polysomnogram is not medically necessary. Our physician reviewer found this 
enrollee has excessive daytime sleepiness and loud snoring. There are diagnoses of hypertension and aortic 
stenosis. Our reviewer found that the records do not mention observed apneas and do not include the Epworth 
sleepiness score or neck circumference. Also, a home sleep study would be a reasonable first step for this 
enrollee. Our physician reviewer also found that there are no conditions that would necessitate an attended 
sleep study, such as severe heart or lung disease or body mass index (BMI) greater than 45. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on October 17, 2022. 
 
You asked the Plan to pay for an eye appointment. You say that the patient did not give the office the correct 
insurence, please reconsider. 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 an eye appointment 
provided on October 17, 2022.