Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that you suffer from multiple sclerosis and 
other chronic conditions which make simple day to day chores and self-care very difficult. Your quality of life 
will suffer without this help. The Plan denied your request. The Plan says Medicare does not cover custodial 
care or personal care attendant services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 27, 2022, billed 
with codes 81226, 81240, 81241, 81227 and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
December 27, 2022, billed with codes 81226, 81240, 81241, 81227 and 81328.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 16, 2023, billed with 
evaluation and management (EM) code 99202. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says "new patient" qualifications were not met. 
 
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 99202 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, documentation shows that 
the enrollee was seen on January 31, 2023, by a physician from the same group practice that paid for evaluation 
and management code 99203 on February 6, 2023. As such, new patient qualifications for the date of service in 
question were not met. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on March 16, 2023, billed with evaluation and management (EM) code 99202.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal orthosis (L0637). 
 
You asked the Plan to pre-approve spinal orthosis. You say that the enrollee has a history of lower back pain 
for several years. The Plan denied your request. The Plan says the enrollee does not meet criteria for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules state that spinal orthoses are covered for certain conditions. 
 
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 spinal orthosis. Our reviewer says that 
the enrollee does not meet criteria for this spinal orthosis. Our physician reviewer found a spinal orthosis is 
covered to reduce pain by restricting mobility of the trunk, facilitate healing following an injury to the spine or related soft tissues, facilitate healing following a surgical procedure on the spine or related soft tissue or 
otherwise support weak spinal muscles. The documentation does not indicate that the enrollee has had any 
surgical procedure. The documentation does not include a physician order form that specifies the medical 
necessity for this orthosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal orthosis (L0637).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for shoulder x-rays provided on April 04, 
2023. 
 
You asked the Plan to waive the copayment for shoulder x-rays. You say that you live on a tight income. 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 in-network basic radiological services provided in a specialists office. 
 
You have been asked to pay a $40 copayment for shoulder x-rays. This item/service falls within the in-network 
basic radiological services provided in a specialists office 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 shoulder x-rays provided on April 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99202 billed for March 3, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 
G0121 provided on March 3, 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 procedure code 99202 billed for 
March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 29540. 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 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29540 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29540 billed for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an application of skin substitute graft to face, scalp, 
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits (15275x10) and Matrion, per 
square centimeter (Q4201x10). 
 
You asked the Plan to pre-approve utilization of skin substitute. You say that you disagree with the denial. The 
Plan denied your request. The Plan says neither Medicare nor the Plan cover this request. Medical studies have 
not proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
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 utilization of skin substitute. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a non-pressure chronic ulcer of the right foot. Per the May 
24, 2023, office visit note, the wound has improved. The problem is being treated with gentamicin, collagen 
sheets and dry dressing. The enrollee also has an ulceration located at the dorsal R5 toe. The provider is 
requesting Matrion for the treatment of the enrollee's non-pressure chronic ulcer of the right foot. There is no 
clinical rationale for the requested item. The enrollee's wound has improved with the present treatment. The 
review has determined that the items/services at issue in this case are not medically reasonable and 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 utilization of skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an application of skin substitute graft to face, scalp, eyelids, mouth, neck, 
ears, orbits, genitalia, hands, feet, and/or multiple digits (15275x10) and Matrion, per square centimeter 
(Q4201x10).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 12, 2022, billed 
with codes 81209, 81216, 81223, 81238, 81241, 81250, 81279, 81298, 81305, 81307, 81311, 81317, 81320. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. 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. The enrollee also has no personal history of cancer. 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 September 12, 2022, billed with codes 81209, 81216, 
81223, 81238, 81241, 81250, 81279, 81298, 81305, 81307, 81311, 81317, 81320.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eyelid surgery to be provided by an OON provider.  
 
You asked the Plan to pre-approve the eyelid surgery. You say that you would be fine seeing another provider 
who is in-network. The Plan denied your request. The Plan says there are in-network providers who can 
provide this service. 
 
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 Plan contract 
says the enrollees POS benefit only applies to nonMedicare covered dental services covered by the Plan. 
 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 eyelid surgery to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on February 21, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says the rules 
say that claims for services furnished on or after January 1, 2010, must be filled no later than the close of the 
period ending 1 calendar year after the date of service.  
 
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 inpatient hospital care was not filed until February 22, 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 inpatient hospital care provided on February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from an IRF level of care.  
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
28, 2022, to December 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the level of care is not supported. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of admission the enrollee could have been anticipated to need a lower 
level of care than inpatient care for less than 2 midnights, such as observation 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 28, 2022, to December 
1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 5, 2022, billed 
with evaluation and management (EM) code 99318. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed units exceed days in time span. 
 
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 99318 is evaluation and management of a patient 
involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval 
history; A comprehensive examination; and medical decision making that is of low to moderate 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 patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on 
the patient's facility floor or unit. 
 
We find that CPT code 99318 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee was seen on October 6, 2021, for services that paid for evaluation and management code 
99318 on November 3, 2021. As such, payment for the services provided on October 5, 2022, were correctly 
denied for exceeding the days in time span. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on October 5, 2022, billed with evaluation and management 
(EM) code 99318.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 12, 2022. 
 
You asked the Plan to pay for the claim is not payable as billed. 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 claim is not 
payable as billed. have not been met. Therefore, we decided that the Plan does not have to pay for the testing 
provided on December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99291, 31500) provided on March 6, 2023. 
 
You asked the Plan to pay for hospital services. You say that these services were necessary and were coded 
correctly. The Plan denied your request. The Plan says this claim was submitted with two incompatible 
diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital services have not been met. Specifically, this claim was submitted with diagnosis codes 
R41.82 (altered mental status, unspecified), and R40.20 (unspecified coma). However, code R41.82 has an 
Excludes1 note with codes within the R40 code group. This means it is generally inappropriate to report these 
diagnoses together. Therefore, we decided that the Plan does not have to pay for hospital services (99291, 
31500) provided on March 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 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 a diagnosis of 
neovascular age-related macular degeneration and has had a trial of at least three doses of Avastin. She has not 
tried and failed the Plan's required drug, Eylea. The records do not show that the required drug would be 
contraindicated or less effective; therefore, Vabysmo 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 Vabysmo.