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

 
We decided that the Plan does not have to pay for lab services (0241U) provided on December 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
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 claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0241U) provided on 
December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6.  
You asked the Plan to pre-approve a Dexcom G6. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87631, 94761, 99072) provided on December 
13, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
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 claim does not show that the required unique identifier 
was reported. Codes 94761 and 99072 have status indicators of "T" and "B" and are not eligible for separate 
payment. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (87631, 94761, 99072) 
provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on January 17, 2023. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the billed codes are not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care provided 
have been met. Specifically, no medical records have been submitted for review. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Natrol melatonin gummies, the Equate famotidine, 
the Cetirizine twin pack, and the Equate ibuprofen provided on January 7, 2023. 
 
You asked the Plan to pre-approve the OTC items. You say that you are appealing the denial not to reimburse 
you for the items. You say your new debit card did not work. The Plan denied your request. The Plan says the 
items were not purchased with the Flex Card. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
items were not purchased with the Flex Card. Therefore, we decided that the Plan does not have to pre-approve 
the Natrol melatonin gummies, the Equate famotidine, the Cetirizine twin pack, and the Equate ibuprofen 
provided on January 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the planned procedure listed under CPT code 63047 is not listed on the 
CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation that you will require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99497, 84153, 84443, 80061, 84439, & 
82947 provided on September 21, 2022. 
 
You asked the Plan to pay for the services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed services. 
 
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 find that CPT code 99497, 84153, 84443, 80061, 84439, & 82947 is not supported in the medical record. 
Specifically, code 99497 is not supported. Records do not show how much face to face time was spent on this 
service. Lab results were not provided to support codes 84153, 84443, 80061, 84439, & 82947. 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 procedure codes 99497, 84153, 84443, 80061, 84439, & 82947 
provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 19, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 19, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 19, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of June 19, 2023, forward. Our physician reviewer found 
the enrollee did not require inpatient mental health treatment beyond June 19, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 19, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 19, 2023, 
forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 3, 2023.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 30, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you just talked with this 
provider and were sent for blood work, and do not feel you should have to pay. 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 for specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 specialist office visit provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not had an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met.  Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer Panel provided 
on January 18, 2023, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81209, 81314, 81334, 81345, 81272, and 81479. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer Panel. You say that this test should be 
covered. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the CGx Comprehensive Complete Cancer Panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGx Comprehensive 
Complete Cancer Panel provided on January 18, 2023, and billed with codes 81162, 81201, 81218, 81292, 
81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network doctor. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for medical supplies and computed tomography 
(CT) scan December 16, 2022.  
 
You asked the Plan to waive the cost share for medical supplies and CT scan. You say that you already paid 
your deductible amount and there is no explanation as to why this amount is not 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 a 20% 
coinsurance for each Medicare-covered medical supply. You must pay a $115 copayment for Medicare-
covered radiological diagnostic services, not including X-rays, performed in a physicians office or at a free-
standing facility (such as a radiology center or medical clinic). Covered services include, but are not limited to 
surgical supplies, such as dressings and other outpatient diagnostic tests - radiological diagnostic services, not 
including x-rays. The provider billed in the amount of $12,420 and the allowed amount is $5,401.26 for the 
date of service. $5,401.26 x 20% = $1,080.25. The provider also charged a $115 copayment. $1,080.25 + $115 
= $1,195.25. Therefore, results in the total cost sharing amount of $1,195.25. 
 
You have been asked to pay a 20% coinsurance for medical supplies and a $115 copayment for CT scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and 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 cost share for medical supplies and computed tomography (CT) scan 
December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87496, 87532 and 87653 billed for date of 
service January 16, 2023. 
 
You asked the Plan to pay for procedure codes 87496, 87532 and 87653. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 find that CPT codes 87496, 87532 and 87653 are not supported in the medical record. Specifically, the 
provided laboratory results do not support that testing was performed for the infectious agents pertaining to 
codes 87496, 87532 and 87653. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 87496, 87532 and 87653 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87496, 87532 and 87653 billed for date of service January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection (64495). 
 
You asked the Plan to pre-approve the facet joint injection. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the third level injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a 
time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA), 
facet cyst ruptures, and radiofrequency ablations (RFA)) that are performed during the same day. 
 
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 facet joint injection. Our reviewer 
says that the LCD criteria is not met. Our physician reviewer found only two levels are considered medically reasonable and necessary at one session.  The third level is not considered medically reasonable and 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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injection (64495).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the abdominal ultrasound provided on 
January 11, 2023. 
 
You asked the Plan to waive the deductible for the abdominal ultrasound. You say that you already paid the 
deductible. 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. Your 
contract with the Plan says that there is a $233 outpatient deductible which applies to outpatient diagnostic tests 
and therapeutic services. Your contract with the Plan also clearly says that enrollees pay a $0 copayment after 
meeting the deductible for outpatient diagnostic radiology. 
 
The records show the deductible was processed correctly. You have been asked to pay $126.96 towards the 
deductible. The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $233 outpatient deductible which applies to outpatient diagnostic tests 
and therapeutic services. This cost sharing is a contractual obligation that had not been met at the time the 
abdominal ultrasound was received on January 11, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the abdominal ultrasound provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 2, 2022, billed 
with code 99153.