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

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 
10, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx testing. The Plan denied your request. The Plan says the 
records do not show that the enrollee has advanced, metastatic, recurrent, or refractory cancer. 
 The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer.  
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stages III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the FoundationOne CDx testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine testing billed with code 87086 for date of service 
April 3, 2023. 
 
You asked the Plan to pay for the urine testing. 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 urine testing is covered when billed with specific 
diagnosis codes. 
 
We looked at the file and Medicare rules. Review of the file shows that the urine testing was billed with 
diagnosis code N32.3 (Diverticulum of bladder). This diagnosis is not listed as one that is covered for this 
service. Based on this information, we decided that Medicare rules for coverage of the urine testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the urine testing billed with code 87086 
for date of service April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99306) provided on March 30, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making or must meet or exceed 45 minutes of total time spent on the date of 
the encounter. 
 
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 nursing facility care. Our reviewer says that the records do not support the code billed. Our reviewer found the records do not show high level of medical decision 
making or at least 45 minutes of total time spent on the date of the encounter. 
 
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 nursing facility care have not been met. Therefore, we decided that the Plan 
does not have to pay for nursing facility care (99306) provided on March 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0152, G0299, G0300, Q5001) 
provided on March 13, 2023, through April 11, 2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the provider did not bill as required by Medicare 
coding regulations. 
 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of home health services have not been met. The claim was billed with 
an invalid therapy and revenue code combination as the home health services reported occupational therapy 
with code G0152 with a skilled nursing revenue code of 055x. We find the Medicare rule for payment of this 
claim has not been met. Therefore, we decided that the Plan does not have to pay for home health services 
(G0152, G0299, G0300, Q5001) provided on March 13, 2023, through April 11, 2023.
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 will benefit from acute rehab to optimize 
the level of functioning prior to returning home, requiring interdisciplinary therapy care. The Plan denied your 
request. The Plan says the enrollee's condition does not meet the Medicare criteria. The Plan says that the 
services needed may be provided safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37222 rendered on March 11, 2023.  
 
You asked the Plan to pay for the service. You say that this should be paid for.  The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 37222 is revascularization, endovascular, open or 
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately 
in addition to code for primary procedure). 
 
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 service. Our reviewer found there is no documentation of a significant lesion in the external iliac artery that required separate treatment. The iliac angioplasty that was 
performed was billed and covered. The documentation does not support that additional work was done to 
justify additional coding.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 37222 rendered on March 11, 2023.
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 still needs to get physical, occupational, 
and speech therapy for continuing to progress with recovery. The Plan denied your request. The Plan says 
based on the available information, the enrollee's condition does not meet the Medicare criteria. The Plan says 
that the services needed may be provided safely in a lower level of care.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 that the enrollee needs to be monitored and you do 
not think the facility can fulfill the needs. The Plan denied your request. The Plan says the required services can 
be provided safely in an alternate setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services (22869) provided April 20, 2023, 
from an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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. 
 Review of this file shows that this provider had a denied authorization for these services and did not obtain an 
approved prior authorization to the Health Plan to request coverage of services prior to providing the care. The 
Plan states the enrollee member did not have approved skilled nursing facility care coverage by the Health Plan 
at the time these services were provided. 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 wound 
care services (22869) provided April 20, 2023, from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the portable oxygen concentrator, rental 
(E1392) an oxygen concentrator (E1390) provided April 20, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that you are asking for the 
additional amount to be waived since you were never notified. 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay 20% coinsurance, every month until the completion or termination of your rental 
agreement. This item/service falls within the Durable medical equipment (DME) and related 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 the portable oxygen concentrator, rental 
(E1392) an oxygen concentrator (E1390) provided April 20, 2021, to December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is enrolled in a clinical trial; therefore, the Plan is not responsible for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Truxima as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of Truxima.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that you are requesting reconsideration and have 
submitted medical records for review. The Plan denied your request. The Plan says payment for code 70450 is 
bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 19, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for platelets, pheresis, pathogen-reduced, each unit (P9073) Transfusion of 
blood and/or blood products (36430) injection, heparin sodium, (heparin lock flush), per 10 units (J1642) 
provided October 24, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that blood transfusions and platelets are part of 
the treatment plan. The Plan denied your request. The Plan says that charges for blood and blood products are 
excluded from coverage under your Plan. 
 
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. the Plan has not provided any information to substantiate their reason to 
continue to deny. The Evidence of Coverage specifically says under Outpatient diagnostic tests and therapeutic 
services and supplies Covered services include Blood - including storage and administration. Coverage of 
whole blood and packed red cells begins only with the fourth pint of blood that you need. - you must either pay 
the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone 
else. All other components of blood are covered beginning with the first pint used. Therefore, we decided that 
the Plan has to pay for platelets, pheresis, pathogen-reduced, each unit (P9073) Transfusion of blood and/or 
blood products (36430) injection, heparin sodium, (heparin lock flush), per 10 units (J1642) provided October 
24, 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, 87801, 
and 87500, billed for date of service January 19, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, 87801, and 87500. The 
Plan denied your request. The Plan says the claim is 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. In this case, we have confirmed that code 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87481, 87641, 87653, 
and 87798, are column II codes to column I code 87801.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. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not support 
the multiple organisms represented by code 87801. Based on this information, we decided that Medicare rules 
for coverage of code 87801 have not been met. 
 
Medicare rules also say that while a physician order is not required to be signed, the physician must clearly 
document, in the medical record, his or her intent that the test be performed. 
 
We find that the submitted documentation does not records showing that ordering physicians intent that the 
testing, represented by code 87500, be performed. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87150, 87481, 87641, 87653, 87798, 87801, and 87500, billed for date of service January 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 31, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 28, 
2023.  
 
You asked the Plan to pay for procedure code 99232. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and follow-up visit. 
 
You asked the Plan to pre-approve the consultation and follow-up visit. You say that the services are needed 
due to concerns with your health due to significant dental disease. The Plan denied your request. The Plan says 
the consultation and follow-up visit services are considered dental and not covered under your medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
consultation and follow-up visit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve OON physical therapy. You say that you are appealing the denial. The Plan 
denied your request. The Plan says in-network providers are available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an OON provider.