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

 
We decided that the Plan does not have to pre-approve GeneSight Psychotropic multi gene panel testing 
(0345U).  
You asked the Plan to pre-approve the genetic testing. You say that you were unaware when you ordered the 
test that the enrollee would be charged $1400. Please remove this charge as the enrollee is unable to afford this 
and your office was not made aware of the cost.  The Plan denied your request. The Plan says the requested 
genetic test, GeneSight Psychotropic multi gene panel, does not meet the requirements for approval. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is diagnosed with depression. Anti-depressant medication was discussed 
but was worried about side effects. Lexapro, Zoloft, and Cymbalta were discussed as options for the enrollee. 
Testing (GeneSight Psychotropic multi gene panel (0345U)) was performed for this enrollee. However, genetic 
testing is not supported as a screening tool due to lack of supportive evidence showing improved overall 
outcomes with its use. Also, there was no clear decision-making between the above drugs for this enrollee 
before getting genetic testing such as differences in potential side effects and benefits. Therefore, criteria are 
not 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve GeneSight Psychotropic multi gene panel testing (0345U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 29, 2023. 
 You asked the Plan to pay for the billed testing. You say that the records support the testing. The Plan denied 
your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The panel was billed using codes 87652, 87798, 87799, 87900, 87481, 87500, and 87640. We looked at the file 
and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is 
no evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, 
a single code with one unit of service should be used. Based on this information, we decided that Medicare 
rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the panel testing billed for date of service August 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temozolomide.

You asked the Plan to pre-approve Temozolomide. You say that the drug is medically necessary. The Plan
denied your request. The Plan says the enrollee is enrolled in a clinical trial.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Temozolomide as part of a clinical trial. The Plan does not
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have
to pre-approve Temozolomide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 12, 2022, billed 
with procedure code 99222. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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 physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation provided describes 
the enrollee with stable vitals, without leukocytosis, without evidence of pyelonephritis, and with plans to await 
urine culture. The documentation did not show a comprehensive examination, nor medical decision-making of 
moderate complexity. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 12, 2022, billed with procedure 
code 99222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SIJ RFA. 
 
You asked the Plan to pre-approve the SIJ RFA. You say that you recommend this procedure to address pain 
and restore function. The Plan denied your request. The Plan says experimental and investigational procedures 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SIJ RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or 
treatment of sacroiliac joint mediated pain are considered experimental and investigational. RFA for 
denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered 
investigational and therefore, 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 SIJ RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SIJ RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional facet joint radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee is in severe pain with 
limited activities of daily living. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for radiofrequency ablation at two levels. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not meet the LCD criteria for coverage for the additional level facet 
joint radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional facet joint radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 15, 
2022, to September 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says requirements of the two-midnight rule are met as long as the admitting provider expects the patient to remain an inpatient across at least two midnights, and 
documentation supports the provider's conclusion. The patient did not require two midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our physician 
reviewer found that the record did not show that at the time of inpatient admission it was reasonable for the 
admitting physician to expect that the patient's necessary hospital care (including earlier emergency department 
and/or observation care) would span two midnights with supporting documentation of the patients history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 15, 2022, to September 16, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 03, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records proving 
medical necessity. 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 laboratory services 
provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the specialist office visit provided on July 
11, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the specialist office visit. You say that you are requesting 
reconsideration of the denied reimbursement. The Plan denied your request. The Plan says this service was not 
authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. The Plan has a POS option to cover 
certain out-of-network services. You will need to obtain authorization from the Plan prior to seeking care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for this 
service. Therefore, we decided that the Plan does not have to provide reimbursement for the specialist office 
visit provided on July 11, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical coverage for porcelain crowns, root canal 
treatment, and fixed bridgework. 
 
You asked the Plan to pre-approve medical coverage for the requested dental services. You say that you feel 
that this should be covered as medical because your current dental condition was caused by treatment for 
cancer. This is a necessary part of your medical rehabilitation. The Plan denied your request. The Plan says this 
is not covered by Medicare as the services are dental in nature. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve medical coverage for involve the care, treatment, filling, 
removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services 
that are not covered or paid for by Medicare. Although the need for dental care may have been caused by a 
medical condition, the services requested in this case are dental by definition. Therefore, we decided that the Plan does not have to pre-approve medical coverage for porcelain crowns, root canal treatment, and fixed 
bridgework.
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 the SNF services are medically necessary. The Plan 
denied your request. The Plan says the services you require could be provided at a different setting. 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81479 billed for date of service October 3, 2023. 
 
You asked the Plan to pay for the billed code. You say that the test meets all of the Medicare coverage criteria. 
The Plan denied your request. The Plan says that code 81479 does not meet the coverage criteria.  
 
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 CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. We find that code 
81479 is supported. The Guardant Reveal test provided is a covered test. The Plan has not shown that a specific 
code has been assigned to the covered test at issue. Based on this information, we decided that the Medicare 
rules for coverage have been met.  Therefore, we decided that the Plan has to pay for procedure code 81479 
billed for date of service October 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine
transportation.

You asked the Plan to pre-approve an exception to supplemental benefits. You say that the requested
transportation is necessary to see a specialist. The Plan denied your request. The Plan says that this request
exceeds the limit of your supplemental benefit. Maximus overturned the Plan's denial. The Plan requested a
reopening and stated that this request exceeds the benefit limit. The Plan is correct in this case.

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 Plan's coverage rules apply in this
case. The Plan covers routine transportation up to 50 miles of driving distance. While plans may offer
supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to
supplemental benefits and your request is for transport over the 50-mile limit. Therefore, we decided that the
Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on 
August 27, 2023. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that the cost share is wrong. 
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 $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for the urgent care services. This item/service falls within the 
urgently needed services 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 copayment for the urgent 
care services provided on August 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CGM supply and the CGM provided 
from April 13, 2023, to September 17, 2023. 
 
You asked the Plan to waive the coinsurance for the CGM and the CGM supplies. You say that you were told 
that the items would be fully covered. 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 Medicare-covered durable medical equipment. 
 
You have been asked to pay $55.70, which is 20% coinsurance of the allowed amount for the CGM provided 
on April 13, 2023 ($278.51 allowed amount x 20% = $55.70). You have also been asked to pay $51, which is 
20% coinsurance of the allowed amount for each CGM supply allowance provided on May 16, 2023, June 16, 
2023, July 17, 2023, August 17, 2023, and September 17, 2023 ($255.01 allowed amount x 20% = $51). These 
items/services fall within the durable medical equipment and related supplies 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 the CGM supply and the CGM provided from April 13, 2023, to 
September 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 
08, 2023, to May 09, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree 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 a $375 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $375 copayment for the inpatient hospital stay. This item/service falls within the in-network inpatient hospital care 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 copayment for 
the inpatient hospital stay provided on May 08, 2023, to May 09, 2023.