Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not supported. 
 
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 99214 is established patient office or other outpatient 
visit, 30-39 minutes. 
 
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 office visit. Our reviewer says that the records do not 
support the billed code. Our reviewer found the provided records do not show that procedure code 99214 was a separate and distinct service from the wound care services provided. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (99214) provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis procedures provided on July 01, 2023, to July 27, 
2023. 
 
You asked the Plan to pay for the dialysis procedures. 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 dialysis procedures 
provided on July 01, 2023, to July 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal screening (Cologuard screening) (81528) 
provided on July 10, 2023. 
 You asked the Plan to pay for the Cologuard screening. You say that your doctor recommended you were due 
for Cologuard, and you followed their orders. You also say that you did not know there was a frequency of one 
Cologuard every three rolling calendar years. The Plan denied your request. The Plan says the benefit 
maximum for this time period or occurrence has been reached. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Cologuard screening, was requested solely for screening purposes. 
However, the 2023 Evidence of Coverage clearly states that the Plan covers one DNA based colorectal 
screening every three years. The record shows that you received your last Cologuard screening on October 13, 
2020, and your colorectal screening benefit had been exhausted. Therefore, we decided that the Plan does not 
have to pay for the colorectal screening (Cologuard screening) (81528) provided on July 10, 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 can handle the therapy requirements and 
if they return home functional decline is expected. The Plan denied your request. The Plan says the request is 
not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is the most 
appropriate setting for the enrollee to achieve the best outcome for their complex medical needs. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from August 
4, 2022, to August 13, 2022. 
 
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 the provider billed PDPM score KDGE1, which requires supporting documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. The documentation available 
for review that pertains to the appropriate look-back period does not support the billed PDPM KDGE1. The 1st 
and 3rd   alphanumeric characters in the PDPM were not correct. The enrollee had a medical history including 
coronary artery disease with an acute myocardial infarction with who was admitted to a skilled nursing facility 
after an acute hospitalization. The documentation available for review does not support the coded physical 
therapy functional score. Additionally, there is no clear documentation to support the member received 
supplemental oxygen or parental fluids or feeding to support the level of nursing care. The partial adjustment to 
PDPM LDYE1 was appropriate. 
 
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 skilled nursing facility (SNF) services rendered from August 4, 2022, to August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on August 10, 2023. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the service was 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 the psychotherapy 
(90837) provided on August 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on August 30, 2023. 
 
You asked the Plan to pay for the psychotherapy (90837). You say that the service was 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 the psychotherapy 
(90837) provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653 and 87641 billed for 
date of service September 13, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653 and 87641. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
codes are not supported for separate payment. 
 
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 codes 87798, 87481, 87653 and 87641 are column II codes to column I 
code 87801; however, 87798, 87481, 87653 and 87641 were each billed with a modifier.  
 
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 procedure codes 87798, 87481, 87653 and 87641. Our 
reviewer says that these codes are not supported for separate reporting or payment. Our reviewer found the 
documentation provided does not include sufficient information to support that these services were separate 
and distinct from the primary code; therefore, these codes cannot be verified as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87798, 87481, 87653 and 87641 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87798, 87481, 87653 and 87641 billed for 
date of service September 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each laboratory service provided on May 
11, 2023, to August 10, 2023. 
 
You asked the Plan to waive the copayment for each laboratory service. You say that you should not be held 
responsible for these services. 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
You have been asked to pay a $5 copayment for each laboratory service. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $15 ($5 copayment x 
3 services = $15). Therefore, we decided that the Plan does not have to waive the copayment for each 
laboratory service provided on May 11, 2023, to August 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo 240mg/24ml vial. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the required test results were not received to support the use of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a diagnosis of  mast cell leukemia. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo 240mg/24ml vial.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a denosumab injection provided on 
October 12, 2022. 
 
You asked the Plan to reduce the coinsurance for a denosumab injection. You say that the enrollee should only 
be charged a $280 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 20% 
coinsurance for Medicare Part B prescription drugs.  
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 reduce the coinsurance for 
a denosumab injection provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service March 15, 
2023. You asked the Plan to pay for procedure code 11721. You say that the records prove medical necessity. The 
Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 is a column II code to column I code 11055. Code 11721 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 11721 
billed for date of service March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found that the record contains no x-rays of the right 
shoulder and no physical therapy program concentrating on shoulder. Medical necessity of an MRI without 
conservative treatment has not been established in the submitted records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the shoulder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 
26, 2023.  
 You asked the Plan to pay for procedure code 86077. You say that medical records were provided. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve whole mitochondrial genome genomic sequence 
(81460). 
 You asked the Plan to pre-approve whole mitochondrial genome genomic sequence. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures (Tier1 and Tier 2) 
may be eligible for coverage when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve whole mitochondrial genome genomic 
sequence. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
provided documentation revealed that there was prior genetic testing (GeneDX Combined MitoGenome plus 
Mito focused Nuclear Gene Panel 202 nuclear genes) performed on this enrollee in 2019 revealing no 
pathogenic mutations. Repeat genetic testing is redundant and would not lead to changes in results or overall 
treatment plan. Therefore, this request for genetic testing will be considered not medically 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 whole mitochondrial genome genomic sequence have not been met. Therefore, 
we decided that the Plan does not have to pre-approve whole mitochondrial genome genomic sequence 
(81460).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gene test (ngs mpn mutation). 
 
You asked the Plan to pre-approve a gene test (ngs mpn mutation). You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that Genomic Sequential Analysis Panels are covered 
when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a gene test (ngs mpn mutation). Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
indicates that the enrollee already had this test. This test only needs to be repeated if the test would continue to 
help guide treatment plans. The notes do not show that the enrollee meets this requirement. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 gene test (ngs mpn mutation) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a gene test (ngs mpn mutation).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (power scooter) (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support the scooter is 
medically necessary nor appropriate for self-care activities in the home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (power scooter) (K0800).