Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carotid sinus baroreflex activation device (Barostim 
Neo system). 
 
You asked the Plan to pre-approve Barostim Neo system. You say that the procedure is medically necessary 
due to an overall lower quality of life due to heart failure symptoms, and the enrollee has failed other 
treatments. The Plan denied your request. The Plan says that this treatment is not shown to be as good as or 
better than standard treatment of heart failure. 
 
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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve carotid sinus baroreflex activation device (Barostim Neo system).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis with additional stabilization (L1686 and 
L2624) provided on June 29, 2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records do not include a diagnosis of hip arthritis. 
 
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 clinical documentation provided does not support the need for a hip orthosis. The enrollee has a 
medical history of lumbar spine pain, radiculopathy, and spondylosis. White the prescription for the hip 
orthosis notes osteoarthritis there is lack of clinical history supporting this in the clinical documentation. There is limited physical examination documentation regarding the enrollees hip range of motion and strength and 
there is no indication of joint instability. 
 
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 hip orthosis with additional stabilization (L1686 and L2624) provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional consultations and testing with out-of-network 
providers at an out-of-area facility. 
 
You asked the Plan to pre-approve the out-of-area services. You say that there is no way of knowing what tests 
would be ordered once the initial evaluation has been completed. You say that the consultation alone should at 
least be approved. You also say that you can perform any requested testing yourself. The Plan denied your 
request. The Plan says there is an approved authorization for an out-of-network consult at the requested facility 
that has not been attended. The Plan also says any additional consultations or testing requested due to the initial 
visit must be provided in-network. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the out-of-area services have not been met. Specifically, there is no indication that the services 
would be urgent or emergent in nature. Therefore, we decided that the Plan does not have to pre-approve 
additional consultations and testing with out-of-network providers at an out-of-area facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 27, 2023. 
 
You asked the Plan to pay for the office visit. 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 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 office visit provided 
on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (27786-54) provided on May 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the use of modifier 54 
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. 
 
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 services. Our reviewer says that the use of modifier 54 is 
not supported by the records provided. Our reviewer found that modifier 54 is not supported as postoperative 
care transfer is not supported. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (27786-54) provided on May 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 office visit provided 
on May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22841 billed for date of service June 19, 
2023. 
 
You asked the Plan to pay for procedure code 22841. The Plan denied your request. The Plan says procedure 
code 22841 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 22841 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 22841 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 22841 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 22841 billed for date of service June 19, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate through 
primary source documentation that the enrollee has a contraindication to, or would have an adverse effect from 
the plan's preferred step one alternatives. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on November 5, 2021, billed with 
procedure code 31645. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 31645 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. 
 
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 testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the record states that the 
bronchoscopy performed on this date was a subsequent bronchoscopy. There is a more specific code to report a 
subsequent bronchoscopy. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on November 5, 2021, billed with procedure code 
31645.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray services and a specialist office visit 
provided on June 29, 2023. 
 
You asked the Plan to waive the copayment for X-ray services and a specialist office visit. 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 $35 
copayment for outpatient diagnostic tests/X-rays and a $45 copayment for physician/practitioner 
services/Medicare-covered visit with a specialist.  You have been asked to pay a $35 copayment for X-ray services and a $45 copayment for a specialist office 
visit. However, since the allowed amount is less than the standard copayment, you only owe $32.42 for the X-
ray services. The total amount you are being asked to pay is $77.32 ($45 + $32.42 = $77.42). This item/service 
falls within the outpatient diagnostic tests/X-rays and physician/practitioner services/Medicare-covered visit 
with a specialist 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 X-ray services and a 
specialist office visit provided on June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic sequential compression garment to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a non-pneumatic sequential compression garment. You say that the supplies 
should be covered. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a non-pneumatic sequential compression garment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for telephone evaluation and management service. You say that the services should 
be covered. The Plan denied your request. The Plan says this is available in-network. 
 
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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for telephone evaluation and management service 
provided on, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #14 provided on July 11, 2023. 
 
You asked the Plan to pay for D2740. You say that you believe the Plan should pay more for this. The Plan 
denied your request. The Plan says this dental work was processed correctly. 
 
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. 
 We looked at the file and Medicare rules. Based on this information, the Plan will pay on the least costly 
method of treatment and the member will be responsible for the remaining balance. Therefore, we decided that 
the Plan does not have to pay for a crown (D2740) for tooth #14 provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95907 billed for date of service May 17, 
2023.  
 
You asked the Plan to pay for procedure code 95907. The Plan denied your request. The Plan says payment for 
code 95907 is bundled into payment for code 95861. 
 
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 95907 
is a column two code to column one code 95861 with a modifier indicator of 0. The column two code is therefore not payable. 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 95907 billed for date of service May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on April 28, 2023. 
 
You asked the Plan to pay for the 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 lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58710. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81518 billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the date of service is the date the test was 
performed. The Plan denied your request. The Plan says the date of service is the date the specimen was 
collected. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The records show that the specimen was collected on January 17, 2019. 
Since the specimen was stored for more than 30 days, the billed date of service must be the date the specimen 
was obtained from storage, not when the test was performed/reported. Based on this information, we decided 
that Medicare rules for coverage of the billed testing have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81518 billed for date of service June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and related services to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and related services. You say that the services should be 
covered. The Plan denied your request. The Plan says this is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and related services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene test billed with code 81225 for date of service 
February 17, 2023. 
 
You asked the Plan to pay for the gene test billed with code 81225. You say that this gene was tested and 
should be paid. The Plan denied your request. The Plan says the code reported is not supported as it describes 
only one gene tested in the comprehensive panel provided. A panel code would be more appropriate in this 
case. 
 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 81225 is CYP2C19 (cytochrome P450, family 2, 
subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, 
*17). 
 
We find that CPT code 81225 is not supported in the medical record. Specifically, the records provided show 
that this was not the only gene tested in this case. The records indicate that a full panel was provided; therefore 
a panel code should be used to report all the genes tested in this case. Based on this information, we decided 
that Medicare rules for coverage of the gene test billed with code 81225 have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene test billed with code 81225 for date of service February 
17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for TissueCypher Barrett's Esophagus assay (0108U) provided December 
12, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that your claim was denied in error, and you are 
requesting it be reprocessed and paid. The Plan denied your request. The Plan says that this service does not 
meet this requirement of the enrollee's Plan of benefits and is excluded from coverage.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of Barrett's esophagus. A TissueCypher assay was performed on a 
biopsy specimen from endoscopy on August 5, 2022. Medicare has noted that the test performed meets 
Advanced Diagnostic Laboratory Test (ADLT) status and is a covered benefit for patients with Barrett's 
esophagus. 
 
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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for TissueCypher Barrett's Esophagus assay (0108U) provided December 12, 2022.  
 
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.