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

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, 
EGFR, ERBB2, EZH2, FLT billed with code 81456 provided on February 12, 2023. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services provided were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that targeted genomic sequence analysis panels are only 
covered for certain indications. 
 
 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 targeted genomic sequence analysis 
panel. Our reviewer says that the documentation does not support that the services rendered were medically 
reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of prostate cancer. The 
testing rendered is only covered in colorectal cancer to establish KRAS or NRAS mutation status for possible 
treatment with cetuximab or panitumumab. The review has determined that the enrollee does not have either 
recurrent, relapsed, refractory, metastatic, or advanced stages Ill or IV cancer; and has not been previously 
tested with a CGP for the same cancer genetic content; and decided to seek further cancer treatment (e.g., 
therapeutic chemotherapy). Therefore, the enrollee did not meet criteria for the services rendered. 
 
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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, 
EGFR, ERBB2, EZH2, FLT billed with code 81456 provided on February 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast reduction (19318). 
 
You asked the Plan to pre-approve the plastic surgery. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if the individual's body surface area and weight of 
breast tissue removed fall above the 22nd percentile, then the surgery is considered medically reasonable and 
necessary with the appropriate criteria. 
 
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 plastic surgery. Our reviewer says 
that the requested breast reduction is not medically necessary. Our physician reviewer found the provided 
documentation indicates that between 100 to 150 grams of tissue are to be removed from each side. The 
reviewer found that this amount is significantly beneath the minimal amount of soft tissue to be removed to 
justify surgery to alleviate symptoms based on body surface area. Therefore, the reviewer found that the 
requested breast reduction is not medically reasonable or 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 plastic surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a breast reduction (19318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's telehealth services provided on May 24, 2023. 
 
You asked the Plan to pay for physician's telehealth services. You say that per emergency CDC and state 
regulations, telehealth has been authorized and approved to be used interchangeably with office visits. The Plan 
denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits. 
 
The Plan contract says if you choose to get one of these services by telehealth, you must use a network provider 
who offers the service by telehealth. 
 
We looked at the file and the Plans rules. The file shows that telehealth services are covered when provided by 
a network provider that offers telehealth services. Based on this information, we decided that the Plans rules 
for coverage of physician's telehealth services have not been met. Therefore, we decided that the Plan does not 
have to pay for physician's telehealth services provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided July 
11, 2023 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you have attached the 
supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says based on 
Medicare guidelines, the ultraviolet (UV) phototherapy wand requested does not meet the requirements for 
approval. 
 
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. The records do not contain any documentation of a diagnosis of 
psoriasis. There is also no indication of intractable psoriasis, as there is no indication you have failed other 
treatments for psoriasis. There are also no other factors described that would justify treatment at home rather 
than alternative sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for 
coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does 
not have to pay for the ultraviolet light therapy system (E0691) provided July 11, 2023
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on October 6, 2022, 
through April 27, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says the Provider is not eligible with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) provided on 
October 6, 2022, through April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the testing provided in this case. 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 the lab services provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 93041-59 
 
You asked the Plan to pay for codes 93005 and 93041-59. You say that you do not believe these codes should 
be bundled. The Plan denied your request. The Plan says these services are not separately payable. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
this case, the codes in dispute have a status indicator of QI, meaning that it is a STV-packaged service.  The 
disputed codes were billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93005 and 93041-59 have not been met. Therefore, we decided that the Plan does not have 
to pay for codes 93005 and 93041-59
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the nasal valves/turbinates 
(30469). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that the requested code is considered a 
covered and reimbursable code by Medicare. The Plan denied your request. The Plan says this is considered 
investigational and therefore is not covered. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal turbinate hypertrophy and nasal 
congestion. There is insufficient literature to support the safety and efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the requested VivAer 
procedure is not medically reasonable or 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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the nasal valves/turbinates (30469).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee x-ray and injection.  
 
You asked the Plan to pre-approve a knee x-ray and injection. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 knee x-ray and injection have been met. Specifically, there is no physician order for the requested services. Therefore, we decided that the Plan 
does not have to pre-approve a knee x-ray and injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 7, 2023. 
 
You asked the Plan to pay for the home health 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 all home health PPS claims must be submitted 
with type of bill 0329. 
 
We looked at the file and Medicare rules. The claim was submitted with type of billed 0324. 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 pay for home health services provided on July 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 26, 2022, to 
December 21, 2022. 
 You asked the Plan to pay for home health services. You say that you are due a reduced payment. 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 October 26, 2022. The NOA was not received by the Plan until February 
28, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 26, 2022, to December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on May 8, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on May 18, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not payable for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 21, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was 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 urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on March 21, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the scooter repairs provided on April 13, 2023. 
 
You asked the Plan to pay for the scooter repairs. You say that you feel you should get your $50 back because 
your scooter was not repaired, and you will have to pay again to have something repaired that should have been 
repaired the first time. The Plan denied your request. The Plan says that on April 10, 2023, you were advised 
the Plan would not cover the $50 fee for the medical equipment company to pick up and repair the scooter. The 
Plan also says that the request for reimbursement cannot be granted as you are responsible for the costs of 
repairs to the owned scooter. 
 
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. Medicare rules also say that repairs to equipment which a beneficiary owns are covered when 
necessary to make the equipment serviceable.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. Without medical records, we are unable to determine 
whether the repairs in dispute were necessary to make the beneficiary owned equipment serviceable. Therefore, 
we decided that the Plan has to pay for the scooter repairs provided on April 13, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter. 
 
Your complaint about your issues with the company not having repaired your scooter is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 8, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 5, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 5, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the appropriate level of 
care. The Plan denied your request. The Plan says the enrollee is in the appropriate level of care and does not 
require a transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's status is stable and improving. There is no documentation that the 
enrollee is capable of being weaned at this time. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving care. There are no services available 
at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 
health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intrapcet procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. 
The Plan says this procedure is investigational and therefore is not covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease. The provided documentation does not indicate a cause for the 
enrollee's pain is not clear. Therefore, the reviewer found that the requested Intracept procedure is not 
medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intrapcet procedure).