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

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) provided on October 7, 2022. 
 
You asked the Plan to pay for Guardant Reveal. 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 Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal (81479) provided on October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound PCR (polymerase chain reaction) panel provided 
on November 21, 2022, billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the wound PCR panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the wound PCR (polymerase chain reaction) panel provided on November 21, 2022, billed with codes 87481 
and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests purchased on 
October 21, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 tests. You say that you would like to know if your insurance 
plan is your Original Medicare coverage or not. You also say that you would like this claim to be reconsidered. 
The Plan denied your request. The Plan says Original Medicare is responsible for coverage of at-home OTC 
COVID-19 tests from April 4, 2022, through the end of the public health emergency. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 tests are an OTC item. The Plan does not offer a supplemental benefit covering this service. 
However, for future purchases, these can be obtained with participating providers and covered by Original 
Medicare when using your Medicare card rather than your Plan card. Therefore, we decided that the Plan does 
not have to pay for the over-the-counter (OTC) COVID-19 tests purchased on October 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 7, 2022, to 
February 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted a corrected claim and 
valid NOA, so you do not know why the Plan is denying this claim. The Plan denied your request. The Plan 
says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 7, 2022. The NOA was not received by the Plan until December 
27, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 7, 2022, to February 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, tumor, soft tissue of leg or ankle area, subfascial 
(eg, intramuscular); 5 cm or greater rendered on November 15, 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 Current Procedural Terminology (CPT) code 27634-76-RT (1 Unit) remains 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 27634 is "Excision, tumor, soft tissue of leg or ankle 
area, subfascial (eg, intramuscular); 5 cm or greater." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure details a 
longitudinal incision was made and taken down exposing the mass. It was solid and nature and well-
demarcated from the surrounding tissue. This was removed in its entirety and sent for permanent pathology.  
However, the operative report does not document the size of the mass. Therefore, records do not support that CPT 27634 was rendered in this case. 
 
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 excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); 5 cm or greater 
rendered on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services rendered on August 24, 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 the credentials listed in the submitted medical documentation aren't separately reimbursable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services rendered 
on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable non-hospital bed. 
 
You asked the Plan to pre-approve an adjustable non-hospital bed. You say that you would like an adjustable 
non-hospital bed to put downstairs. You do not want to rent one. You would like to purchase one and pay your 
cost share. The Plan denied your request. The Plan says the requested bed is not a hospital bed and is not DME 
in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Please note, you 
were approved for a semi electric hospital bed and you refused the delivery and cancelled the order. Therefore, 
we decided that the Plan does not have to pre-approve an adjustable non-hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Baroreceptor stimulator. 
 
You asked the Plan to pre-approve a Baroreceptor stimulator. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Baroreceptor stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical 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 Baroreceptor stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Baroreceptor stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on October 28, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted with DEX Z-code Z00D5, 
which is not covered for the billed testing. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on October 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on October 1, 2021. 
 
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 only 2 of the 3 key components were 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that there was no medical decision 
making of high complexity. The records did not support that the presenting problems were of high severity, 
posing an immediate significant threat to life and function. 
 
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 emergency department services (procedure code 99285) rendered on October 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 You asked the Plan to pre-approve Orthovisc. 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. 
 
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 Orthovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 29, 2022, to July 
27, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA with 
the final claim. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 29, 2022. The NOA was not received by the Plan until October 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 29, 2022, to July 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2078) provided on November 
28, 2022. 
 
You asked the Plan to pay for the opioid treatment services. 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 Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. The service was billed be an individual provider and not an approved 
facility. Based on this information, we decided that Medicare rules for coverage of the opioid treatment 
services have not been met. Therefore, we decided that the Plan does not have to pay for opioid treatment 
services (G2078) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5225) and mandibular partial 
denture (D5226) provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous dentures did not fit well. They 
would cut your gums and caused gum disease. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 5, 2021. Therefore, 
we decided that the Plan does not have to pay for the maxillary partial denture (D5225) and mandibular partial 
denture (D5226) provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pure Wick catheter (A9999). 
 
You asked the Plan to pre-approve a Pure Wick catheter. You say that this device would be a good help for you 
to avoid certain situations with incontinence. The Plan denied your request. The Plan says this is not a covered 
benefit under your Plan. 
 
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. The requested urinary system is unproven and not medically 
necessary for managing urinary incontinence due to insufficient evidence of efficacy. Based on this 
information, we decided that Medicare rules for coverage of a Pure Wick catheter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Pure Wick catheter (A9999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80323, 80324, 80336, 80346, 80348, 80349, 
80353, 80354, 80355, 80356, 80358, 80359, 80360, 80361, 80364, 80365, 80366, 80367, 80368, 80370, 80371, 
80372, 80373, 83992, 80321 and 80345 billed for date of service August 1, 2022. 
 
You asked the Plan to pay for procedure codes 80323, 80324, 80336, 80346, 80348, 80349, 80353, 80354, 
80355, 80356, 80358, 80359, 80360, 80361, 80364, 80365, 80366, 80367, 80368, 80370, 80371, 80372, 80373, 83992, 80321 and 80345. You say that these services were necessary and are supported in the medical record. 
The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 80323, 80324, 80336, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 
80358, 80359, 80360, 80361, 80364, 80365, 80366, 80367, 80368, 80370, 80371, 80372, 80373, 83992, 80321 
and 80345 all have a Status Indicator of I on the Physician Fee Schedule. This means that these procedure 
codes are not valid for Medicare purposes. Based on this information, we decided that Medicare billing rules 
have not been met. Of note, presumptive drug tests are typically billed with a single unit of one code from the 
80305-80307 code set range. Therefore, we decided that the Plan does not have to pay for procedure codes 
80323, 80324, 80336, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80358, 80359, 80360, 80361, 80364, 
80365, 80366, 80367, 80368, 80370, 80371, 80372, 80373, 83992, 80321 and 80345 billed for date of service 
August 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on December 5, 2022. 
 
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 records do not support the billed code. 
 
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 99309 is Subsequent Nursing Care. 
 
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 nursing facility care. Our reviewer says that the billed 
code is not supported. Our reviewer found there was no indication that the wound was infected or worsening. 
There was no significant problem or new problem. 
 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 nursing facility care have not been met. Therefore, we decided that the Plan 
does not have to pay for nursing facility care (99309) provided on December 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 5, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
Medicare rules state that claims must be submitted no later than one 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 emergency department visit was not filed until December 3, 2022. 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 an emergency department visit provided on 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291, 99053) provided on March 26, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are not supported by the records. 
 
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 codes 99291 & 99053 are not supported in the medical record. Specifically, code 99053 has a 
status of "B" and is not separately payable. Code 99291 is not supported in the records. This code represents 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30- 
74 minutes. Records do not show 30-74 minutes of critical care services. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for critical care services (99291, 99053) provided on March 26, 2022.