Persius/hicric huggingface dataset:
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to a 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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder panel (81479) provided on December 12, 
2022. 
 
You asked the Plan to pay for the CxBladder panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 the CxBladder panel have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the CxBladder panel (81479) provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 4, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on April 20, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is a more 
appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab services in this case were billed with multiple codes, and not 
one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), bone replacement graft for ridge preservation-per site (D7953), 
consultation-diagnostic service provided by a dentist or physician other than requesting dentist or physician 
(D9310), the unspecified adjunctive procedure, by report (D9999), and the guided tissue regeneration, natural 
teeth-resorbable barrier, per site (D4266) provided on April 3, 2023 and April 7, 2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. Additionally, the unspecified adjunctive procedure, by report is not a covered 
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, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service April 7, 2023. Specifically, the 
Plans contract states that the maximum allowable dental benefit is $4,000 per year. The Plan has issued 
payment in the amount of $4,000 ($481 + $783 + $1,436 + $245 + $374 + $681) for dental services provided 
this calendar year. Therefore, you have exhausted the allowable benefit for the dental services provided in this 
case. Additionally, an unspecified adjunctive procedure, by report (D9999) is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), bone replacement graft for ridge preservation-per site (D7953), 
consultation-diagnostic service provided by a dentist or physician other than requesting dentist or physician 
(D9310), the unspecified adjunctive procedure, by report (D9999), and the guided tissue regeneration, natural 
teeth-resorbable barrier, per site (D4266) provided on April 3, 2023 and April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low-level laser treatment provided by a chiropractor on 
April 7, 2023. 
 
You asked the Plan to pay for the low-level laser treatment. You say that the enrollee felt that the chiropractic 
services were covered by any chiropractor. The Plan denied your request. The Plan says that the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the low-level laser treatment provided by a chiropractor on April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the home ventilator system for 9 additional months. 
 
You asked the Plan to pre-approve the home ventilator system. You say that  The Plan denied your request. The 
Plan says that a home ventilator is not medically necessary for this patient because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our 
reviewer says that the home ventilator system for 9 additional months is medically necessary. Our physician 
reviewer found that the enrollee has been using intelligent volume-assured pressure support (iVAPS) since 
June of 2022 with the appropriate treatment. Therefore, to change the enrollee's device now would be 
substandard to 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 the home ventilator system have been met. Therefore, we decided that the Plan 
has to pre-approve 12-month home ventilator system.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), anti-reflective coating (V2750), 
and frames (V2020) provided on May 6, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), anti-reflective coating (V2750), and frames 
(V2020). You say that you paid $87.16 and should have money coming back. The Plan denied your request. 
The Plan says based on your EOC, you are responsible for any amount over the $200 retail price. The Plan also 
says that the charge exceeds the allowable rate for the services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses. The Plan rules also say that you are responsible 
for any amount over the $200 price. Based on this information, we decided that the Plan's rules for coverage of 
progressive lenses (V2781), anti-reflective coating (V2750), and frames (V2020) have not been met. Therefore, 
we decided that the Plan does not have to pay for progressive lenses (V2781), anti-reflective coating (V2750), 
and frames (V2020) provided on May 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general patient convenience items provided December 
13, 2022. 
 
You asked the Plan to pay for the general convenience items. You say that you were told by the Plan that the 
enrollee would be covered from the date of admission until discharge. The Plan denied your request. The Plan 
says general non-medical convenience items that are provided to a member during a custodial stay are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the general convenience items were used in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pay for the general patient convenience items provided December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999) provided on May 
9, 2023. 
 
You asked the Plan to pay for unspecified preventive procedure (D1999). You say that on the claim, this 
provider was listed as out-of-network and you were charged full price. You also say that on the Plan website, 
this provider is in-network, which is the reason you went to him. The Plan denied your request. The Plan says 
there is no coverage for unspecified preventive procedure (D1999). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
unspecified preventive procedure (D1999) provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 3, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care supplies. You say that you are requesting reconsideration stating 
these supplies are a separately billable expense. The Plan denied your request. The Plan says this provider is 
not a network provider. They have determined that these services are 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. 
 
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 wound care supplies provided on February 3, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the pain from the wisdom tooth continued after 
a few days of the extraction. You also say you contacted the dentist to return. The Plan denied your request. 

The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 18, 2023. 
Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) 
provided on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6010, A6199, A6219) provided on 
December 27, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says there were network providers 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
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 at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for wound care supplies (A6010, A6199, A6219) provided on December 27, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0241U) provided on March 15, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on March 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transluminal angioplasty (PTA) of the 
left leg. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PTA is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee's symptoms of back pain, 
leg fatigue, and being limited to short-distance walking with pain that improves while sitting down are not 
consistent with vasculogenic claudication. Furthermore, there is a disconnect in that the provider assessment 
notes severe stenosis based on duplex in the left external iliac artery; however, the duplex reports only 
moderate stenosis. The velocities in that area are not severely elevated.  The enrollee has an arterial branchial 
index (ABI) of 0.9 with only mild change with exercise, and it should be noted that the ABI in the previously 
treated leg is worse than the leg in question. The criteria for coverage are not met and the PTA is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous transluminal angioplasty (PTA) of the left leg.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the enrollee does not choose the lab that is 
used. The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 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 laboratory services provided on April 18, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0326U for date of service September 29, 
2022. 
 
You asked the Plan to pay for procedure code 0326U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0326U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, 
gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
We find that CPT code 0326U is not supported in the medical record. Specifically, the medical records do not 
include an order and report of the billed date of service. In addition, the medical records indicate a report date of September 29, 2022, and a collection date of September 20, 2022. This discrepancy means the validity and 
accuracy of the claim cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of procedure code 0326U have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 0326U for date of service September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GIAnomics Oncology Germline Panel provided on 
March 13, 2023, and billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81403, 81404, 81405, 81406, 81407, 81408, and 81479. 
 
You asked the Plan to pay for the GIAnomics Oncology Germline 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 GIAnomics Oncology Germline Panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the GIAnomics Oncology 
Germline Panel provided on March 13, 2023, and billed with codes 81162, 81201, 81292, 81295, 81298, 
81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 81408, and 81479.