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

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (0345U) provided April 14, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of denied services. 
The Plan denied your request. The Plan says GeneSight Psychotropic is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. GeneSight Psychotropic has not been shown to be useful, is not 
considered medically necessary and appropriate, and is not covered by Medicare. It is a noncovered test by 
Medicare per DEX Diagnostics. 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 the GeneSight 
Psychotropic test (0345U) provided April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued use non-invasive ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of ventilator. You say that the enrollee does fit the criteria for 
a non-invasive ventilator, and you request a standard appeal  The Plan denied your request. The Plan says 
continuation of non-invasive ventilator is not medically necessary. 
 
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 continued use of ventilator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has COPD and is on methadone. The enrollee has had a home 
ventilator since March 22, 2021. The enrollee is using the device consistently. The device is being used in the 
spontaneous/timed (S/T) mode, which can be provided with BiPAP. The records do not show that BiPAP has 
been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can 
be provided with BiPAP. Continuation of the home ventilator 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 continued use of ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 months continued use non-invasive ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not show failure of 
bilevel positive airway pressure (BIPAP) as described. The enrollee's documentation does support chronic 
respiratory failure with elevated carbon dioxide (CO2), however, clear evidence of failure is not present in 
records provided. Hence, the enrollee does not meet standard for home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
January 25, 2022. 
 
You asked the Plan to waive the copayment for the office visit (99213). You say that the service should be 
covered. 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 vision services. 
 
You have been asked to pay a $30 copayment for the office visit (99213). This item/service falls within the 
vision services 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 office visit (99213) 
provided on January 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908 and 95885 billed for date of service 
April 11, 2023.  
 
You asked the Plan to pay for procedure codes 95908 and 95885. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 95908 and 95885 is bundled into 
payment for code 95861. 
 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 
95908 and 95885 are column II codes to column I code 95861 with a modifier indicator of 0. The column II 
codes are therefore not payable. 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 codes 95908 and 95885 billed for date 
of service April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 64447. You say that you disagree with the denial. 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 64447 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 64447 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64447 billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), and custom fabricated wheelchair seat cushion (E2609). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and custom 
fabricated wheelchair seat cushion. You say that when three or more power seating functions/actuators/motors 
are provided, one unit of E2311, one unit of E2377, and one unit of E2313 are allowed. The Plan denied your 
request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. The Plan 
also says the notes do not clearly explain why a skin protection cushion, positioning cushion or skin protection 
and positioning cushion is not sufficient to meet the enrollee's needs, as required by Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, harness, 
expandable controller, and custom fabricated wheelchair seat cushion. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. There is not a medical need for the upgraded electronics. Our reviewer also found that the 
documentation does not support that the enrollee has a need for an additional seat width, that there are 
significant postural asymmetries, indication for specialized hardware or a prefabricated cushion. Our reviewer 
also found that the requested accessories are 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 an electronic connection, harness, expandable controller, and custom fabricated 
wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an electronic connection (E2311), harness (E2313), expandable controller (E2377), and custom fabricated 
wheelchair seat cushion (E2609).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 has not tried and failed the Plan's required drugs, alendronate, ibandronate, or risedronate and Prolia or zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; therefore, Evenity is not reasonable or 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 Evenity.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861 and 95999 billed for date of service 
August 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were requested out of medical 
necessity. The Plan denied your request. The Plan says the billed codes are 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. 
 
We find that CPT code 95999 is not supported. Code 95999 was used to describe Train of Four testing. Train 
of Four testing is bundled with the intraoperative neuromonitoring and not separately reportable. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. 
 
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 95861 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE. The 
documentation does not show justify the excess units billed. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 95861 and 95999 billed for date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 5, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating the Plan 
has denied this claim for services not authorized by network/primary care providers. The Plan denied your 
request. The Plan says Medicare rules say that health Plans can require enrollees to get care from network 
providers. 
 
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 an office visit provided on April 5, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed date of 
service is incorrect. 
 
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 payment for CPT code 81518 is not supported in the medical record. Specifically, the records 
show that the specimen was collected on November 8, 2016. The claim should be billed with the date the 
specimen was collected. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
April 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on April 21, 2023. 
 
You asked the Plan to pay for the office visit (99213). You say that the service should be covered. 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 office visit (99213) 
provided on April 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 11, 2023, to 
May 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim was billed with a valid 
certification period. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 11, 2023, to May 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95938, 95927, and 95940 billed for date of 
service March 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services reduce the risk of debilitating 
deficits.  The Plan denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The intraoperative neuromonitoring services were billed with place of 
service code 15, a mobile unit. The services are supported for the place of service where the surgery was 
provided. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95938, 95927, and 
95940 billed for date of service March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that a CardioMEMS device is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a CardioMEMS device is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. 
 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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not 
medically necessary as the enrollee does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. Our reviewer also found that there is not a 
medical need for the upgraded electronics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on May 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for specialist services. You say that you said that you did not believe authorization was required for this office visit and service. The Plan denied your request. The Plan says a prior authorization is required if the enrollee is seeking non-emergency out-of-network care.
 
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 specialist services provided on May 9, 2023, by an 
out-of-network (OON) provider.