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

 
We decided that the Plan does not have to pay for the drug testing (80307, G0482) provided on April 16, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
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 drug testing was not filed until January 18, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the drug testing (80307, G0482) provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx comprehensive genomic 
profiling test (F1LCDx) (0239U) provided December 3, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that it is the responsibility of the referring physicians 
to obtain prior authorization for testing. The treating physician ordered the F1LCDx test to assist in treatment 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for coverage. 
 
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. NCD criteria states NGS testing is reasonable and necessary and 
covered when a patient has not been previously tested with the same test using NGS for the same cancer 
genetic content. The enrollee had received the same testing, with the same diagnosis code which was approved 
by the Plan on May 19, 2022.  Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne Liquid CDx comprehensive genomic profiling test (F1LCDx) (0239U) provided December 3, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to this appointment. The Plan denied your request. The Plan says the requested transport exceeds 
your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. We verified that the requested 
transportation is greater than 50 miles in driving distance. Based on this information, we decided that the Plans 
rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing, CASR (CAR, EIG8, extracellular 
calcium-sensing receptor, FHH, FIH, GPRC2A, HHC, HHC1, NSHPT, PCAR1) (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial. The Plan denied 
your request. The Plan says these genes are currently listed under Tier 2 Noncovered Codes/Gene 
Combinations that are not covered and are denied at 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 looked at the file and Medicare rules. The requested test is a Tier 2 genetic test that is excluded from 
coverage per LCD L35000. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing, 
CASR (CAR, EIG8, extracellular calcium-sensing receptor, FHH, FIH, GPRC2A, HHC, HHC1, NSHPT, 
PCAR1) (81479).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
  You asked the Plan to pre-approve SNF care. You say that the services are necessary because the enrollee is a 
fall risk and unable to walk. The Plan denied your request. The Plan says the services are not medically 
necessary because the enrollee's maintenance care needs can be addressed safely and effectively with non-
skilled personnel. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services rendered on December 15, 2020. 
 
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 Medicare rules say that a Medicare Health plan must receive claims within 12 months from 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 services was not filed until June 8, 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 anesthesia services rendered on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on June 30, 2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was processed 
according to the allowable. 
 
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 without an appropriate DEX Z-
Code as required by LCA A57526. 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 June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF services are necessary for the member to gain 
strength, endurance, and balance. The Plan denied your request. The Plan says the requested SNF admission is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete ultrasound scan of abdomen (76700) provided on 
September 8, 2021. 
 You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says current procedural terminology (CPT) code 76700 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, we have confirmed that code 76700 is a column II code to column I code 93975; however, 76700 
was billed with a modifier.  
 
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 ultrasound. Our reviewer says that the documentation 
does not support procedure code 76700. Our reviewer found that the medical record includes documentation of 
a complete ultrasound, however this procedure would be included in procedure code 93975 if documented, and 
therefore modifier -59 cannot be verified. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for a complete ultrasound scan of abdomen (76700) provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31625-59 provided on October 6, 2022. 
 You asked the Plan to pay for procedure code 31625-59. You say that the medical records support the use of 
modifier 59 with code 31625. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 31625. 
 
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, we have confirmed that code 31625 is a column II code to column I code 31641; however, 31625 
was billed with a modifier.  
 
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 procedure code 31625-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 31625. Our reviewer found the operative report 
describes bronchoscopy with tumor removal and biopsy on the tumor removed. In this case, modifier -59 is not 
supported, as the biopsy would be included in the tumor treatment. Therefore, this procedure denied correctly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 31625-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 31625-59 provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on August 6, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the medical records support the billing of 
code 99222 provided on August 6, 2022. The Plan denied your request. The Plan says the medical records do 
not support the billing of code 99222 provided on August 6, 2022. 
 
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 99222 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says that the medical 
records do not support the billing of code 99222 provided on August 6, 2022. Our reviewer found criteria for 
99222 are not met as key elements of the history are absent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 provided on August 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel (87481, 87491, 87496, 
87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661 and 87798) provided on October 24, 
2022. 
 
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 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 urinary tract infection (UTI) panel (87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 
87641, 87651, 87653, 87661 and 87798) provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on January 9, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies (K0553) provided on September 14, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says payment is included in 
the SNF payment. 
 
The Plan must follow Medicare rules. Medicare rules say that any DME or oxygen furnished to inpatients in a 
covered Part A stay is included in the skilled nursing facility (SNF) PPS rate.  
 
We looked at the file and Medicare rules. Payment for the requested supplies is included in the SNF PPS rate. 
The supplies are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
supplies (K0553) provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and related supplies.  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a sleep study report was not received. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a replacement device is not medically necessary. The enrollee has a diagnosis of 
obstructive sleep apnea, and according to the enrollee, currently has a device. The enrollee indicates that it is 
the supplies that are needed, and that the device itself was replaced one year ago. The medical records do not 
document the enrollee's need for a replacement device. There is no history or sleep study confirming the 
diagnosis of obstructive sleep apnea, and no indication of how long the enrollee has been on CPAP. There is no 
assessment of compliance with use. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this type of bed would help with 
transfers. The Plan denied your request. The Plan says total electric beds are denied by Medicare as not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on November 15, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you are asking for reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the podiatry services 
provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on November 18, 
2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visit provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided from  
September 14, 2021, to October 19, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
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 nursing facility care was not filed until January 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the nursing facility care provided from September 14, 2021, to 
October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service December 
26, 2022. 
 You asked the Plan to pay for procedure code 99215. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99215 is bundled into 
payment for code 90970. 
 
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, we have confirmed that code 99215 
is a column II code to column I code 90970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99215 billed for date of service December 26, 
2022.