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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2023, billed with 
codes 87798, 87653, 87640, and 87481. 
 
You asked the Plan to pay for the testing billed. You say that the tests were performed per order from the 
referring physician. 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. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on June 30, 2023, billed with codes 87798, 87653, 87640, and 87481.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 26, 2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you thought the Plan 
would fully cover this stay. 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 $350 
copayment per day for days 1-5 and a $0 copayment per day after day five of each inpatient hospital stay.  
 You have been asked to pay a $350 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
five or for the day you were discharged. You have been asked to pay a total of $1,400 ($350 copayment per day 
x 4 days = $1,400). 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 inpatient hospital stay 
provided from June 26, 2023, to June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical first radiographic image (D0220) provided on 
January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 Plan's 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 January 18, 2023. 
Therefore, we decided that the Plan does not have to pay for periapical first radiographic image (D0220) 
provided on January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the ConfirmMDx test (81551) provided March 3, 2023. 
 
You asked the Plan to pay for  the laboratory testing. You say that you are appealing the denial for 
ConfirmMDx for prostate cancer. The Plan denied your request. The Plan says the requested test does not meet 
the coverage criteria. 
 
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 records show that the prostate biopsy was also performed on 
March 3, 2023. The ConfirmMDx test was ordered on the same day as the biopsy. Per NCCN guidelines, 
ConfirmMDx is not recommended to be done at the same time as the biopsy and not without evidence that 
another biopsy is yet warranted. Based on this information, we decided that Medicare rules for coverage of the 
laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for  the 
ConfirmMDx test (81551) provided March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve sprint peripheral nerve stimulator. You say that the enrollee has chronic 
back pain and nothing else has helped. The Plan denied your request. The Plan says this service is experimental 
and not covered. 
 
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 sprint peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found The SPRINT PNS device is experimental for degenerative low back pain.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sprint peripheral nerve stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sprint PNS.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 provided on May 3, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, medical records submitted 
do not include an order that specifically list what test(s) are to be performed in the custom panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0483 provided on May 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not need additional visits. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has had 36 sessions of physical therapy. The 
enrollee continues to make very gradual progress, but their improvement in terms of range of motion and 
strength have largely plateaued. It is understandable that the enrollee continues to be limited with function due 
to their rotator cuff tear, but there needs to be some degree of reasonable progress with therapy. The enrollee 
can continue with a home exercise program. Therefore, the 4 visits of additional physical therapy 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 the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anticoagulant management provided on June 13, 2023, by an out-of-network (OON) provider.

You asked the Plan to pay for anticoagulant management. You say that the service was correctly coded and should be payable. The Plan denied your request. The Plan says this was not authorized.

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 anticoagulant management provided on June 13, 2023, by an out-of-network (OON) provider.
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 admission to the LTACH is necessary 
for wound care. You say wound care done at home will cause you to have another infection. The Plan denied 
your request. The Plan says admission to an LTACH is not 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 there is no documentation indicating the medical necessity for admission to an 
LTACH. You do not require services at the LTACH that are not available at the acute care hospital where you 
are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97530 provided on April 28, 2023. 
 
You asked the Plan to pay for procedure code 97530. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not supported as billed. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 97530 based on Medicare criteria. Medicare rules say documentation requirements 
for therapy services indicates that the amount of time for each specific intervention/modality provided to the 
patient is not required to be documented in the Treatment Note. However, the total number of timed minutes 
must be documented. The medical record clearly shows the total number of timed minutes correctly. Therefore, 
we decided that the Plan has to pay for procedure code 97530 provided on April 28, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 12, 2023. 
 
You asked the Plan to pay for the ambulance services . You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the primary insurance needs to be billed for the services. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the ambulance services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on May 31, 2023. 
 
You asked the Plan to pay for D9215. You say that this dental work was medically necessary. The Plan denied 
your request. The Plan says the denied dental service is not a covered benefit. 
 
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local 
anesthesia (D9215) provided on May 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Immune Globulin. 
 
You asked the Plan to pre-approve Immune Globulin. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for the medication requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Immune Globulin. Our reviewer says 
that the medication is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has idiopathic thrombocytopenic purpura. The record provided does not establish that the requested 
drug is being prescribed for a clinical scenario for which coverage is available under the rules. The elements of 
the coverage criteria are not satisfied.  The requested service is not 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 Immune Globulin have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Immune Globulin.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0482 for date of service April 14, 2023. 
 
You asked the Plan to pay for code G0482. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation shows 
there was 23 drug classes tested. This means code G0482 is not supported. Based on this information, we 
decided that Medicare rules for coverage of code G0482 have not been met. Therefore, we decided that the 
Plan does not have to pay for code G0482 for date of service April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 81003 and 87481 for date of service April 7, 2022. 
 
You asked the Plan to pay for codes 81003 and 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. Medicare rules also say that providers must 
report the actual number of units provided for each procedure code. 
 
In this case, the CPT Code Manual definition of code codes 81003 is urinalysis, by dip stick or tablet reagent 
for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy. 
 
The CPT Code Manual definition of code codes 81003 and 87481 isinfectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique. 
 
We find that CPT codes 81003 and 87481 are not supported in the medical record. Specifically, there is no 
urinalysis results listed in the result; therefore, code 81003 is not supported. We find that 5 units of CPT code 
87481  are not supported in the medical record. The medical record only supports 3 units of CPT code 87481 
were tested (Candida albicans, Candida lusitiniae, and Candid dublineiensis). Based on this information, we 
decided that Medicare rules for coverage of codes 81003 and 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for codes 81003 and 87481 for date of service April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that  the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. The 
Plan says the enrollee has chronic low back pain due to the presence of non-vertebrogenic pathology that can 
explain the source of pain.  
 
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 the Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 You asked the Plan to pre-approve foot orthotics. You say that you coverage includes external devises at no 
charge and the requested inserts should be covered. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the requested foot inserts (L3020) are not a covered inserts for a person with diabetes, and 
you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-
approve foot orthotics.