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

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (81225, 81226, 
81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81238) provided on November 21, 2022.  
 
You asked the Plan to pay for the comprehensive pharmacogenetics panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
comprehensive pharmacogenetic testing have not been demonstrated in the peer-reviewed literature. There is 
no documentation how this testing will impact treatment.  
 
-The Plan follows Medicare rules. Medicare rules say that Pharmacogenetics testing will be considered 
medically reasonable and necessary if the criteria in the rules section of this letter are met. 
 
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 comprehensive pharmacogenetics panel. 
Our reviewer says that this service is not medically necessary. Our physician reviewer found that in this case, 
there is no specific clinical rationale for the requested laboratory testing. The clinical value and effectiveness of 
comprehensive pharmacogenetic testing have not been demonstrated in the literature. The review has 
determined that there is no documentation how this testing will impact treatment. The requested testing was not 
medically necessary or reasonable. 
 
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 comprehensive pharmacogenetics panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel (81225, 81226, 
81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81238) provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the mattress is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the air mattress is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a powered pressure-reducing air 
mattress. 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 enrollee meets criteria for the requested mattress. Provided records in this case do not 
document the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to 
improve over the past month, during which time the enrollee has been on a comprehensive ulcer treatment 
program or the enrollee has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or the enrollee 
has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days as 
required by the Local Coverage Determination (LCD) Pressure Reducing Support Surfaces - Group 2 L33642 
and the Local Coverage Article Pressure Reducing Support Surfaces - Group 2 - Policy Article. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service December 12, 2022. 
 
You asked the Plan to pay for code 99152. You say that this service is separately payable. The Plan denied 
your request. The Plan says you billed the wrong code for this service.  
 
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 rules say that code G0500 should be used instead of 99152 when the moderate sedation 
services are performed during a colonoscopy.  In this case, the medical records clearly show that the moderate 
sedation services were performed as part of a colonoscopy, so it was not appropriate to bill code 99152.  
Instead, code G0500 should have been billed. Therefore, we decided that the Plan does not have to pay for code 
99152 billed for date of service December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pigmented lesion assay (PLA) provided on September 
20, 2022.  
 
You asked the Plan to pay for the PLA testing. You say that this should be paid due to medical necessity. 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 PLA testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the pigmented lesion assay (PLA) 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36247, 36248, 37243, 
76937). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the requested procedure may be 
of significant benefit to the enrollee with reduced mortality and morbidity compared to alternative surgical 
options which the enrollee is hoping to avoid. The Plan denied your request. The Plan says the requested 
procedure is considered experimental and investigational. 
 
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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the requested procedure has been used to treat intractable knee pain due to osteoarthritis, but the procedure continues to be considered to be investigational. The reviewer 
found that the references provided by the requesting physician are very small series and in fact the statements 
at the conclusion of the articles state that further investigation is considered necessary in order to prove the 
long-term efficacy of the procedure. Therefore, the reviewer found that the requested procedure is not 
medically reasonable or 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36247, 36248, 37243, 76937).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0326U) provided on February 5, 2023. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was necessary and is supported in the 
medical record. 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 Guardant360 testing 
have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (0326U) 
provided on February 5, 2023.
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 you are determined to get better with the in-house 
rehabilitation to get better and don't feel like skilled nursing will help at all. The Plan denied your request. The 
Plan says you not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient hospital services provided from November 16, 
2021, to November 26, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the principal diagnosis code is not supported, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9, defined as sepsis unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the assigned principal 
diagnosis code and DRG. Our physician reviewer found the documentation does not indicate that the treatment 
ordered by the treating medical providers supports a diagnosis code of A41.9 and R65.20. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from November 16, 2021, to November 26, 2021, at the DRG originally 
billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the test 
is not an approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications. 
 
We looked at the file and Medicare rules. The requested testing is not FDA approved or cleared as a companion 
in vitro diagnostic test. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with an oncologist for a second 
opinion, to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you were diagnosed with stage IV pancreatic 
cancer. You have seen oncologists within the network, and they are not recommending any treatment due to the 
advanced stage of the disease and other health issues. You do not want to see a provider within the network. 
You would like an objective opinion. The Plan denied your request. The Plan says you must see network 
providers for all services. Alternative providers are available in-network for a second opinion. 
 
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 (99205) with an oncologist for a second opinion, to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on 
November 29, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 
87591, 87661, 87481, 87651 and 87653. 
 You asked the Plan to pay for the UTI 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 UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on November 29, 2022, billed with codes 87500, 87641, 
87798, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99152 is bundled into payment for code 45385. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 99152 is a column II code to column I code 45385. While code 
99152 was billed with modifier -59, the medical records provided do not show that the service billed with the  
-59 modifier is a distinct procedural service. Therefore, we decided that the Plan does not have to pay for 
procedure code 99152 billed for date of service December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J8499 for date of service May 26, 2022. 
 
You asked the Plan to pay for code J8499. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code is not payable as billed. 
 
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 J8499 is prescription drug, oral, non chemotherapeutic, 
nos. 
 
We find that CPT code J8499 is not supported in the medical record. Specifically, code J8499 has the status 
indicator as E1 which states it is a non-allowed item or service under any Medicare outpatient benefit. This 
service is not payable as billed.  Based on this information, we decided that Medicare rules for coverage of code J8499 have not been met. 
Therefore, we decided that the Plan does not have to pay for code J8499 for date of service May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laser hair removal rendered on January 4, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is statutorily non-covered. 
 
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 procedure code A9270 is not supported in the medical record. Specifically, this code's definition is 
"non-covered item or service." Therefore, it cannot be covered. 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 laser hair removal rendered on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and a candy 
apple red shroud (A9270) for the approved power wheelchair.  
 
You asked the Plan to pre-approve the requested components. You say that all requested items should be 
approved.  The Plan denied your request. The Plan says neither E2300 or A9270 are considered medical in 
nature and cannot be covered.  
 
The Plan must follow Medicare rules. Medicare rules say that equipment must serve a medical purpose to be 
covered. The rules specifically note that a power seat elevator is not primarily medical in nature. 
 
We looked at the file and Medicare rules. The candy apple red shroud is not considered medical in nature as it 
is a cosmetic feature. The E2300 seat elevator is statutorily noncovered. Based on this information, we decided 
that Medicare rules for coverage of the requested components have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and a candy apple red shroud 
(A9270) for the approved power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and skin testing to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and skin testing 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 and skin testing to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CPAP device. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the provided records in this case do not document sleep study testing showing an apnea hypopnea 
index (AHI) or respiratory disturbance index (RDI) greater than or equal to 15 events per hour, or an AHI or 
RDI greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms 
of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, 
ischemic heart disease, or history of stroke. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).