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 May 31, 2023, billed with 
codes 87481, 87150, 87798, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that the lab results were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 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. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on May 31, 2023, billed with codes 87481, 87150, 87798, and 87801.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health care visits provided on January 
12, 2023, to February 14, 2023. 
 
You asked the Plan to pay for the outpatient mental health care visits. You say that you are requesting 
reconsideration for the denied claims. 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 outpatient mental 
health care visits provided on January 12, 2023, to February 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the enrollee is high risk for falling and 
would benefit from physical therapy. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that it is not 
clear that the enrollee is homebound, as the enrollee was able to attend a clinic appointment unaccompanied. 
The enrollee does not have documented skilled therapy needs. It is not clear that the enrollee has an acute 
illness or injury, for which skilled therapy is indicated. The current medical evaluation should be completed to 
better decide if skilled services of any kind are indicated physical therapy, occupational therapy, and speech 
therapy, and at what level inpatient, home health, or outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service 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 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 an office visit provided 
on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth $4, #6, #7, and #11 
and pontics (D6242) for teeth #8, #9, and #10. 
 
You asked the Plan to pre-approve D6752 and D6242. You say that you need this dental work. The Plan denied 
your request. The Plan says the requested dental services are not medically necessary. 
 
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. The Plan covers D6752 and 
D6242 when the services are medically necessary and reasonable.  
 
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 D6752 and D6242. Our physician 
reviewer found when teeth have severe bone loss around them, their prognosis is guarded/poor. Bridges should 
not be placed on teeth with this prognosis. The bridge is likely to fail.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6752 and D6242 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6752) for teeth $4, #6, #7, and #11 and pontics (D6242) for teeth #8, 
#9, and #10.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80307, 83789, and G0480 
 
You asked the Plan to pay for codes 80307, 83789, and G0480 for date of service April 13, 2023.. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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 find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation does not include an order that specifically lists what tests are to be performed in the custom 
panel provided. In this case, we have confirmed that code 83789 is a column II code to column I code 80307. 
This claim has not been billed with an appropriate modifier to bypass the edit. While code 83789 was billed 
with the modifier -59, the medical records provided do not show that the service billed with the -59 modifier is 
a distinct procedural service. 
 
Based on this information, we decided that Medicare rules for coverage of codes 80307, 83789, and G0480 for 
date of service April 13, 2023. have not been met. Therefore, we decided that the Plan does not have to pay for 
codes 80307, 83789, and G0480
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on June 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66989). 
 
You asked the Plan to pre-approve extracapsular cataract removal with insertion of intraocular lens prosthesis. 
You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 
necessary. The records do not show that the enrollee is currently being treated with drops to lower eye pressure. 
 
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 extracapsular cataract removal with 
insertion of intraocular lens prosthesis. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
support that the enrollee was using glaucoma/ocular hypotensive eye drops prior to the proposed cataract 
extraction with micro-invasive glaucoma surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracapsular cataract removal with insertion of intraocular lens prosthesis have 
not been met. Therefore, we decided that the Plan does not have to pre-approve extracapsular cataract removal 
with insertion of intraocular lens prosthesis (66989).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 5, 2023, to June 
23, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 5, 2023, to June 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 9, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87529, 87625, 87591, 87661, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a 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. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 9, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87529, 87625, 
87591, 87661, 87641 and 87500.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22612). 
 
You asked the Plan to pre-approve arthrodesis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Medicare criteria for reasonable and necessary are not met because use of this device 
as a stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. More research is needed. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis (22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is need of the requested medical 
equipment and has submitted medical documentation for review. The Plan denied your request. The Plan says a 
review of the current medical literature does not support the Life2000 device to be reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD but no 
documented failure of BiPAP or BiPAP with average volume-assured pressure support (AVAPS). There is no 
supporting data to suggest need for a home ventilator. Pulmonary function tests (PFT) noted, but this is not a 
standard of care indication for BiPAP, BiPAP with AVAPS or home ventilator. Hence, no home ventilator 
indicated per documentation provided at this time. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires a LTACH level of care. 
You also say the enrollee is currently stable for discharge. The Plan denied your request. The Plan says it is not 
necessary for the enrollee to be in a LTACH in place of an acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically necessary in this case. Our physician reviewer 
found the enrollee does not require services at a LTACH that are not available at the acute care hospital. There 
are no services available at a LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. Given there are offered alternatives, the admission to a LTACH is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 9, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI edit was made in error. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier 
indicator of 0. The column II 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 81456 
billed for date of service April 9, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #10. 
 
You asked the Plan to pre-approve D2740. You say that food and liquids get stuck in your current crown. The 
Plan denied your request. The Plan says that this replacement is not medically necessary. 
 
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. The Plan covers D2740 when 
the services are medically necessary and reasonable. 
 
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 D2740. Our reviewer says that this 
crown is medically necessary. Our physician reviewer found this area of the tooth that has been exposed is 
prone for plaque and food accumulation, and decay can form around the crown, and potentially get larger. Z 
replacement crown for this enrollee would be beneficial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D2740 have been met. Therefore, we decided that the Plan has to pre-approve a 
crown (D2740) for tooth #10.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that I20.8 has an Excludes1 note in relation to I25.10. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on April 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is currently receiving the proper care needed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied replacement CGM. 
The Plan denied your request. The Plan says the denial of authorization for the CGM is correct because the 
clinical records did not indicate that the enrollee's current CGM was defective or broken. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
  The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement continuous glucose monitor (CGM).