Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a multi-disciplinary 
approach to help manage their medically complex issues. The Plan denied your request. The Plan says the 
records do not show that is it medically necessary for the enrollee to be in LTACH in place of an acute care 
hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. 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 health plan. Given there are offered alternatives, LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on July 6, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions 
(D7321) and nitrous oxide/anxiolysis, analgesia (D9230). 
 
You asked the Plan to pre-approve alveoloplasty not in conjunction with extractions and nitrous 
oxide/anxiolysis, analgesia. You say that the services are necessary. The Plan denied your request. The Plan 
says the services are not covered. 
 
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 pre-approve 
alveoloplasty not in conjunction with extractions (D7321) and nitrous oxide/anxiolysis, analgesia (D9230).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 21, 2022, billed 
with procedure codes 95870-XP-LT and 95870-XP-RT. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid.  The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. This claim was inappropriately billed with pos 11 as documentation 
indicates the service was provided in the hospital setting. 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 November 21, 2022, billed with procedure codes 
95870-XP-LT and 95870-XP-RT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17004 billed for date of service June 15, 
2023.  
 
You asked the Plan to pay for procedure code 17004. You say that the medical records support the billed units. 
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 17004 is 1. The MAI value for this code is 2. You billed 25 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 17004 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 17004 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6,2023, billed with 
codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87651, 87500, 87801, 87641. 
 
You asked the Plan to pay for the genetic testing billed. You say that as you are an independent laboratory, you 
do not have access to physician notes and reports. Please take these circumstances in evaluating these claims for potential reimbursement. 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 
April 6,2023, billed with codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87651, 87500, 
87801, 87641.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that you were advised by a plan representative 
that a copayment for a primary care physician (PCP) visit was $0. You also say that you did not know this 
provider was out-of-network. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 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 the office visit provided on March 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that osteogenesis stimulators are only covered for certain 
indications. 
 
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 an osteogenesis stimulator. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found you sustained a nondisplaced left calcaneus fracture on June 30, 2023. 
Your most recent left foot x-ray on August 29, 2023, shows cortical disruption along distal plantar aspect of the 
calcaneus. The documentation does not support that you have nonunion of a long bone fracture, have failed 
fusion of a joint other than spine, or have congenital pseudarthrosis). Therefore, you do not meet criteria for the 
requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88108 and 88305 billed for September 9, 
2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 16, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88108 and 88305 billed for September 9, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45385 and 45380 billed for date of service 
November 17, 2022.  
 You asked the Plan to pay for procedure codes 45385 and 45380. You say that you disagree with the Plan's 
denial. 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 codes 45385 and 45380 is 1. The MAI value for these codes is 2. You already 
submitted a claim for the exact  
 codes, making it a total of 2units of each of these codes billed, exceeding the MUE. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 45385 and 45380 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 45385 and 45380 billed for date 
of service November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 24, 2023, billed with 
codes 87500, 87641, 87798, G0452, 87481, 87651, 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that you do not see patients and are dependent 
on receiving patient information from the ordering provider. 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 
July 24, 2023, billed with codes 87500, 87641, 87798, G0452, 87481, 87651, 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on January 27, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
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. The panel in this case was billed with multiple codes and not one unit 
of one code as required by LCA A58726. Based on this information, we decided that Medicare rules for 
coverage of the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab panel provided on January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 2, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the drug testing provided on May 2, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomographic angiography (CTA) scan of the heart and a 
computed tomographic angiography (CTA) scan of the abdomen and pelvis. 
 
You asked the Plan to pay for the CTA scans. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 pay for the CTA scans. Our reviewer says that the 
CTA scans were medically necessary. Our physician reviewer found the record indicates that the enrollee has 
severe aortic stenosis and is undergoing evaluation for a procedure. The provided records establish the medical 
necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are satisfied. The requested service was 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 CTA scans have been met. Therefore, we decided that the Plan has to pay 
for a computed tomographic angiography (CTA) scan of the heart and a computed tomographic angiography 
(CTA) scan of the abdomen and pelvis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 49329 and 47379 billed for May 30, 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 -79 modifier is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that modifier -79 reports an unrelated procedure by the 
same physician during a postoperative period.  
 
We looked at the file and Medicare rules. The file shows that procedure codes 49329 and 47379 were 
incorrectly billed with the -79 modifier. The records do not support that the procedures were unrelated to 
previous postoperative services. Therefore, we decided that the Plan does not have to pay for procedure codes 
49329 and 47379 billed for May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
June 26, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 pay for the 
urine polymerase chain reaction (PCR) panel rendered on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 14, 2023, billed with 
codes 81162-90, 81351-90, 81209, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90-GYx3, 81201-90, 
81292-90, 81295-90, 81298-90, 81307-90, 81317-90 and 81321-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. 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 
June 14, 2023, billed with codes 81162-90, 81351-90, 81209, 81314-90, 81334-90, 81345-90, 81272-90, 
81479-90-GYx3, 81201-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90 and 81321-90.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen identified with code J1459 for 480 units. 
 
You asked the Plan to pre-approve Privigen. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Privigen is only covered for certain indications. 
 
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 Privigen. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has lung transplant immunosuppression form anti-rejection medications. The 
enrollee has IgG level of 634. No current infections or recurrent infections. Notes says that the enrollee has no 
rejection. Report Brinch showing Pseudomonas and Penicilliummspecies but not that enrollee has current 
infection. Possible colonization (which is not documented). There is no indication of pneumonia or current bacterial lung infection. Therefore, the enrollee does not have a diagnosis/condition that meets criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen identified with code J1459 for 480 units.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 19, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on April 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

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