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

 
We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81232, 81335) provided on 
March 20, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PGx tests must demonstrate analytical validity, 
clinical validity, and clinical utility to be considered reasonable and necessary for coverage. 
 
We looked at the file and Medicare rules. A search of the MolDX registry does not show a technical 
assessment has been performed on the MyBestMed Panel. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for genetic testing (81225, 81226, 81232, 81335) provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says this service was not approved. 
 
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 
an office visit to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 25, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 20, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 25, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency clinic services provided on March 4, 2023. 
 
You asked the Plan to pay for the emergency clinic services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the provider is not eligible for Medicare payment. 
 
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 emergency clinic services provided on 
March 4, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Zilretta injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that an additional injection is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 injection. Our reviewer says that the 
requested injection is medically reasonable and necessary. Our physician reviewer found that the enrollee has 
received one prior dose of Zilretta with improvement. There is some evidence that a repeat dose of Zilretta may 
be safe, reasonable, and effective. Since the enrollee has had several standard corticosteroid injections without 
response, it does appear that the extended release would be reasonable, possibly more effective, and safe. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a Zilretta injection.  
 
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 the genetic testing provided on March 22, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 22, 2023, billed with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, and 81401.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99308) provided on April 4, 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 service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10160 
provided on March 28, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for nursing facility care (99308) 
provided on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a drug test provided on September 01, 
2022. 
 
You asked the Plan to pay for an office visit and a drug test. 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 an office visit and a drug 
test provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this should have been considered a 
routine eye exam. 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 $40 
copayment for vision care. 
 
You have been asked to pay a $40 copayment for the eye exam. This item/service falls within the vision care 
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 record shows this claim was approved and you are responsible for the cost share amount. Therefore, we 
decided that the Plan does not have to waive the copayment for the eye exam provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an OON provider.  
 
You asked the Plan to pre-approve a consultation. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says this service was not approved. 
 
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 
a consultation to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push wheelchair and accessories (E0955, E0961, 
E0971, E0973, E1028, E1161, E2231, E2609, E2617, K0040, K0108). 
 
You asked the Plan to pre-approve a push wheelchair and accessories. 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. 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 a push wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a push wheelchair and accessories (E0955, 
E0961, E0971, E0973, E1028, E1161, E2231, E2609, E2617, K0040, K0108).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection. 
 
You asked the Plan to pre-approve Synvisc. You say that this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronic Acid Injections for Knee Osteoarthritis 
are covered after failure of or contraindication to intra-articular glucocorticoid injections. 
 
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 Synvisc. Our reviewer says that the 
injection is not medically necessary. Our physician reviewer found the records show no trial of glucocorticoid 
injections or any reason they would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Synvisc injection.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, 
K0108). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's upper limb strength and function are adequate for the enrollee to 
be able to control the power options using their own switches which are included in the allowance of these 
power options. 
 The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is non-ambulatory and requires a power wheelchair for mobility and performing basic 
daily activities. The enrollee cannot perform pressure relief independently due to upper extremity weakness and 
requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
enrollee requires power elevating leg rests for positioning of the lower extremities and lower extremity 
spasticity. The complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 
power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options via a joystick. These components are 
required to operate 3 or more power options on a group 3 power wheelchair. Given the positioning needs of the 
enrollee's lower extremities, the enrollee also requires the footplate extension. Therefore, the expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311) is medically necessary as well as 
the footplate extension (K0108). 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2311, E2313, E2377, K0108).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an OON provider.  
 
You asked the Plan to pre-approve a consultation. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says this service was not approved. 
 
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 
a consultation to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on September 16, 2022, and billed with codes 87798 and 87801. 
 
You asked the Plan to pay for the urine PCR panel testing. 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 testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on September 16, 2022, and billed with codes 87798 and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive percutaneous sacroiliac (SI) fusion 
(27279).  
 
You asked the Plan to pre-approve a minimally invasive percutaneous SI fusion. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for coverage.  
 
The Plan follows Medicare rules. Medicare rules say that this procedure is covered when the criteria in the 
rules section of this letter 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 minimally invasive percutaneous SI 
fusion. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
detailed documentation is not evident regarding diagnostic imaging studies that demonstrate any left sacroiliac 
joint pathology. There are other plausible causes of pain. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the enrollee 
does not meet the LCD criteria for coverage. 
 
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 minimally invasive percutaneous SI fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a minimally invasive percutaneous sacroiliac (SI) fusion 
(27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you need a second opinion. The Plan denied 
your request. The Plan says you must receive your care from a network provider. 
 
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 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on February 3, 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 a valid primary diagnosis code was not 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. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, diagnosis code F06.4-
Anxiety disorder due to known physiological condition has a "code first" note. The underlying condition must 
be listed first. 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 
February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided on 
November 08, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that you do not feel you 
should have to pay this 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 a $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an in-network specialist visit. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 an in-network specialist visit provided on November 08, 2022.