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

 
We decided that the Plan does not have to pay for TissueCypher Barrett's Esophagus Assay (0108U) provided 
June 21, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that your claim for the TissueCypher Barrett's 
Esophagus test was denied in error and you are requesting it to be reprocessed and paid. 
 The Plan denied your request. The Plan says this service does not meet the medically necessary requirements 
of the Plan benefits. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the 
TissueCypher Barrett's Esophagus test from June 21, 2022, at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. The provided medical records in this case consist of an 
endoscopy report, a pathology report on esophageal biopsies showing Barrett's metaplasia and the results of the 
TissueCypher Barrett's Esophagus test. Records from the treating physician do not document necessity of the 
test in addition to the pathology testing already performed and the follow-up endoscopy recommended in three 
years. The TissueCypher Barrett's Esophagus test report states that the test is indicated for patients with non-
dysplastic, indefinite for dysplasia and low-grade dysplasia Barrett's esophagus. The provided records do not 
document non-dysplastic, indefinite for dysplasia and low-grade dysplasia Barrett's esophagus. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for TissueCypher Barrett's Esophagus Assay (0108U) provided June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on December 19, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0315U) provided on October 5, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and have submitted 
medical records for review. 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 genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0315U) provided on 
October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics and cardio hereditary 
genetics testing provided October 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please look at the attachment and reconsider the 
charges which were previously denied. The Plan denied your request. The Plan says the criteria for coverage 
has not been met for the comprehensive pharmacogenetic and cardio hereditary genetics testing. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the test is described as a genetic based cardiovascular risk factor screening test in which 
multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of 
pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a 
diagnostic test. There is no evidence to support its role in this patient's clinical management. In summary, the 
requested testing is not considered 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the comprehensive pharmacogenetics and cardio hereditary genetics testing provided 
October 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation (A0130) provided on August 
12, 2022. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that this is the first time you ever had 
to use an ambulance transport. You also say that you didn't realize you had to use a designated provider. The 
Plan denied your request. The Plan says you are responsible for paying the full cost of services that arent 
covered by our plan, either because they are not plan covered services, or plan rules were not followed. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when this benefit is provided through the Plans designated 
provider.  
 
We looked at your request, the records in the case file, and the rules. This service was not provided by the 
Plans designated routine transportation provider. Based on this information, we decided that the Plans rules 
for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to 
pay for wheelchair van transportation (A0130) provided on August 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 21, 2022 to 
March 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree that the NOA date 
and the claim date must match. 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 February 21, 2022 to 
March 22, 2022.
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 the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the records do not show that LTACH services are 
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 continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87640, 87641, 87651, 87653, 
87798 and 87801) provided on November 18, 2022. 
 You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says these services are not supported 
as medically necessary and are not the standard of care. 
 
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 laboratory services have been met. 
Specifically, the medical records provided include only test results. There is no signed physician order, nor are 
there any physician notes or medical records from the referring provider to support that this testing was 
medically necessary and appropriate for the enrollees condition, and that this was being treated by the 
referring provider. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 
87640, 87641, 87651, 87653, 87798 and 87801) provided on November 18, 2022.
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 out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 7, 2021, billed with codes 
95955-26-XU, 95885-26-59 x2, 95937-26 and 95907-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95955-26-XU, 95885-26-59 x2, 95937-26 and 95907-26 
is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery), Needle electromyography, 
each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited (List separately in addition to code for primary procedure), Neuromuscular 
junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method, and Nerve conduction studies; 1-2 studies. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that in this case, the procedure report 
does not support criteria for the procedure codes 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 the imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on July 7, 2021, billed with codes 95955-26-XU, 
95885-26-59 x2, 95937-26 and 95907-26.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services received on June 19, 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 that anesthesia codes are reimbursed to anesthesia providers only. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The rendering provider is a certified registered nurse anesthetist. The plan has 
not forwarded valid denial, as this provider type is allowed to bill for anesthesia. Therefore, we decided that the 
Plan has to pay for anesthesia services received on June 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0509 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code G0509. You say that the patient was seen by two different 
providers on this date. 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 G0509 is 1. The MAI value for this code is 2. You 2 units of this code, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 
G0509 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0509 
billed for date of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and intravenous infusion provided on  
October 31, 2022. 
 
You asked the Plan to pay for the office visit and intravenous infusion. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the provider is a registered nurse, which 
cannot bill Medicare directly. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for an office visit and intravenous infusion provided on October 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorper.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673 and E0675) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the device. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0673 and E0675) provided on November 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 19, 2022, 
to March 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 February 19, 2022, to 
March 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on September 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit".  
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 services. Our reviewer says that the use of code 99223 is 
not supported by the records provided. Our reviewer found that the provided records in this case do not 
document a comprehensive history including a chief complaint, an extended history of present illness, a review 
of all additional body systems and a complete past, family and social history. As such, the documentation does 
not support procedure code 99223. 
 
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 the services (99223) provided on September 6, 2022.