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 January 5, 2023, billed with 
codes 81439 and 81442. 
 
You asked the Plan to pay for the testing billed. You say that specialized testing was ordered for the enrollee. 
The Plan denied your request. The Plan says an appropriate code was not billed. 
 
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. The file shows that a hereditary cardio gene panel was provided. This 
panel was not billed with a single code as required. Additionally, a unique identifier was not billed 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 January 5, 2023, 
billed with codes 81439 and 81442.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you have had this injection 
before, and this is medically necessary. The Plan denied your request. The Plan says this 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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no concordant radiological image-based diagnostic lumbar 
radiculopathy, radicular pain, or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis. Therefore, you do 
not meet the coverage criteria for the requested lumbar ESI. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Bevacizumab and Trametinib. 
 
You asked the Plan to pre-approve the medications. You say that the requested drugs are medically necessary 
for the enrollee's condition.  The Plan denied your request. The Plan says the use of the requested drugs is not 
medically necessary for the enrollee.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 medications. Our reviewer says that 
the enrollee does not meet the criteria for the requested drugs. Our physician reviewer found the requested 
drugs are considered experimental/investigational for the enrollee's condition. They do not meet any of the 
compendia or literature, so they cannot be recommended for 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 medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the use of Bevacizumab and Trametinib.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 15, 2023, to 
July 20, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says payment of DRG 853 is not supported, and 
payment of DRG 660 may be more supported. 
 
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 codes A41.51, A41.81, and I50.31. 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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the documentation does not support a DRG of 853 as there is no 
sepsis. DRG 660 is more supported by the records.  
 
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 rendered from July 15, 2023, to July 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service March 19, 
2023, to April 17, 2023. 
You asked the Plan to pay for the billed services. You say that the original submission date was within the 
deadline. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 19, 2023. The case file shows that the initial NOA was submitted 
with type of bill 322. A valid NOA was not received by the Plan until May 13, 2023. As more than 30 days 
passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, 
we decided that the Plan does not have to pay for the home health care billed for dates of service March 19, 
2023, to April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 8, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
covered. 
 
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 file shows that the billed unique identifier, Z00D5, is 
not covered for the billed testing with code 81479. 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 
genetic testing provided on September 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on July 3, 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 the guidelines state that fungal infection of the nail (tinea unguium or onychomycosis) 
can be verified by direct microscopic examination with potassium hydroxide, fungal culture of desquamated 
subungual material, or fungal stain of nail clippings fixed in formalin. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the PCR testing of this patients left foot scaling skin was not medically reasonable or necessary. 
The medical documentation does advise that this patient is having itching and scaling skin plantar aspect of left 
foot. A sample of this scaling skin was sent for PCR testing. The longstanding standard of care for the 
evaluation of fungus in skin and toenails is the performance of both KOH and fungal culture on the specimen. 
These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this patients scaling skin 
required PCR testing as compared to KOH and fungal culture. 
 
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 pay for a fungal infection polymerase chain reaction (PCR) panel provided on July 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that computer-assisted 
surgical navigation is medically necessary. The Plan denied your request. The Plan says computer-assisted 
surgical navigation 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 computer-assisted surgical navigation. 
Our reviewer says that the requested computer-assisted surgical navigation is not considered medically 
reasonable and necessary. Our physician reviewer found the documentation does not support that computer-
assisted surgical navigation is medically necessary or that criteria for coverage are met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99211) provided on August 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for code 
99211 is bundled into code 93291. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with the global surgery indicator of 
"XXX" in the MFSDB can be paid separately without a modifier. 
 
We looked at the file and Medicare rules. In this case, code 93291 has global surgery indicator XXX. As the 
global surgery concept does not apply here, the billed code 99211, can be paid separately without the use of a 
modifier. Based on this information, we decided that Medicare rules for coverage of the services have been 
met. Therefore, we decided that the Plan has to pay for the services (99211) provided on August 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you are requesting 
reconsideration of payment for the services rendered. The Plan denied your request. The Plan says Medicare 
rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary 
unless the provider or supplier is enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on April 07, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you dis agree 
with the copayment. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) benefit category. 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 coinsurance 
for durable medical equipment (DME) provided on April 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision examination provided on August 
25, 2023. 
 
You asked the Plan to waive the copayment for the vision examination. You say that you thought the visit 
should fall under "glaucoma care" and should have a $0 copayment. 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 $40 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.  
 You have been asked to pay a $38.19 copayment for the vision examination, which is less than the standard eye 
examination. This vision examination falls within the vision care benefit category. The record shows a 
diagnosis of benign neoplasm of right choroid which makes the exam medical in nature. 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 vision examination provided on August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on June 6, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted medical 
documentation to support and are requesting that the claim be reprocessed and paid. The Plan denied your 
request. The Plan says the provider is not enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical disc arthroplasty. 
 
You asked the Plan to pre-approve a cervical disc arthroplasty. You say that the case was denied for a two level 
disc replacement. You say you are doing a single level disc replacement at C3-4. The Plan denied your request. 
The Plan says your request is not medically necessary at this time. 
 
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 cervical disc arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. 
 
 Our physician reviewer found detailed documentation is not evident regarding significant objective deficits 
corroborating significant pathology at the C3-4 level. The exam demonstrated intact strength, sensation, and 
reflexes. The enrollee's range of motion is full. Additionally, the magnetic resonance imaging (MRI) of the 
cervical spine dated March 10, 2023 showed shallow spur disc complex and minimal facet arthrosis, mild right 
and moderate to moderately severe left foraminal encroachment and anteroposterior (AP) diameter of the 
central canal 11mm at the requested surgical level (C3-4). These findings are similar to the remaining levels in 
the cervical spine, reflecting multi-level disease. While artificial disc arthroplasty has been proven efficacious 
in certain cervical scenarios, in this case, the enrollee does not fit the indications for the procedure. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested cervical disc arthroplasty at C3-4 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 a cervical disc arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cervical disc arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 
19, 2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a postoperative follow-up visit, and the application of body 
cast provided on July 27, 2023. 
 
You asked the Plan to pay for a postoperative follow-up visit, and the application of body cast. You say that 
this is supported in the records. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 a postoperative follow-up visit, and the application of body cast provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental sales tax (D9985) provided on August 28, 2023. 
 
You asked the Plan to pay for the dental service. You say that your tooth was removed by the provider which 
has been aching and causing issues while eating and drinking. The Plan denied your request. The Plan says 
sales tax 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 item at issue is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental sales tax 
(D9985) provided on August 28, 2023.