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

 
We decided that the Plan does not have to pay for procedure code 95868 billed for date of service May 19, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the trapezius muscle was tested bilaterally. The 
Plan denied your request. The Plan says the billed code 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 95868 is needle electromyography; cranial nerve supplied 
muscles, bilateral. We find that CPT code 95868 is not supported in the medical record. Specifically, the 
records do not identify a separate diagnostic service with a formal report. The testing provided was an integral 
to the main procedure and not separately payable. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 95868 billed for date of service May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panels provided on January 30, 2023. 
 
You asked the Plan to pay for the lab panels. The Plan denied your request. The Plan says this is not medically 
necessary, and the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab panels have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing panels provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the office visit provided on June 19, 2023. 
 
You asked the Plan to reimburse you for the outpatient service. You say that you should be reimbursed for this 
service. The Plan denied your request. The Plan says that the billing provider has opted out of Medicare. The 
Plan also says that payment cannot be made to a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support that the rendering provider has opted out 
of Medicare. Additionally, you are not expected to know how the service is going to be billed, or if a different 
provider will be billing for the service other than who you saw. Therefore, we decided that the Plan has to 
reimburse you for the office visit provided on June 19, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. You say that this service is medically 
necessary. The Plan denied your request. The Plan says that the service was not coded properly. 
 
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 the guided 
tissue regeneration 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 the guided tissue regeneration. Our 
reviewer says that the requested service is medically necessary. Our physician reviewer found review of the 
documentation indicates that the patient requires multiple extractions and the future placement of 
implants. After extractions, guided tissue regeneration may be used to preserve the socket for implant insertion 
in the future. In the areas of #27 and #30 where alveolar bone has diminished, it is medically reasonable and 
necessary to use this procedure to preserve the bone for future implant placement. 
 
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 the guided tissue regeneration have been met. Therefore, we decided that the 
Plan has to pre-approve guided tissue regeneration (D4266).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve paravertebral facet joint injections. You say that you are requesting 
reconsideration of the original denial. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
 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 paravertebral facet joint injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD criteria for a 
successful block is 80% pain relief. This was not achieved and therefore, the request is deemed not 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 paravertebral facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve paravertebral facet joint injections (64493, 64494).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 15, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Home health claims must be submitted with type 
of bill 329. 
 
We looked at the file and Medicare rules. The claim was billed with type of bill 0323. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on May 15, 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 
for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 the enrollee is not safe for LTACH transfer and the enrollee's needs are best and most 
appropriately met in their current 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services and 
an office visit (99214).  
 
You asked the Plan to pay for OIVIT services and an office visit. 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. 
 
In this case, the CPT Code Manual definition of code 99214 is: Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of code 99214 
have not been met. 
 
The rules also say that OIVIT is not reasonable and necessary for any indication. Services comprising an 
Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished 
pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not have to pay for Outpatient 
Intravenous Insulin Therapy (OIVIT) services and an office visit (99214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided on January 19, 2023. 
 
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 records do not support the code billed. 
 
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 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, the records do not provide a 
complete description of the test represented by the not otherwise specified code. 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 (87798) provided on January 19, 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says all services that would be provided in the LTACH are 
being provided and approved for the enrollee in the current acute care setting. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the liposculpting (15877) provided from February 23, 2021, 
to January 14, 2022. 
 
You asked the Plan to pay for the liposculpting. You say that this surgery was vital and necessary for your 
health. You say that the surgeries were not cosmetic in nature. You also say that you feel you should be 
reimbursed for these treatments. The Plan denied your request. The Plan says the services were cosmetic in 
nature and therefore are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable. 
 
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 liposculpting. Our reviewer says that the 
liposculpting was not considered medically reasonable and necessary in this case.  Our physician reviewer found the record indicates that you have lipodystrophy and weight loss following 
gastric bypass surgery. The record provided does not document that the services were for the prompt repair of 
accidental injury or to improve the functioning of a malformed body member or are necessary for the diagnosis 
or treatment of an illness or injury. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the 
liposculpting services were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the liposculpting have not been met. Therefore, we decided that the Plan does 
not have to pay for the liposculpting (15877) provided from February 23, 2021, to January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloSure testing provided on February 16, 2023. 
 
You asked the Plan to pay for the AlloSure testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that the AlloSure testing is not supported in the medical record. Specifically, neither a laboratory order 
nor medical records from the ordering/treating physician were provided to show the intent of the testing 
performed. Based on this information, we decided that Medicare rules for coverage of the AlloSure testing 
have not been met.  Therefore, we decided that the Plan does not have to pay for the AlloSure testing provided 
on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7140 x 6). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on authorization 20232786078925 when the 
Plan approved eight extractions. Therefore, we decided that the Plan does not have to pre-approve extractions 
(D7140 x 6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
29, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the service should 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 a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a specialist office visit provided on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services coded as 99239 performed on 
May 13, 2023. 
 
You asked the Plan to pay for 99239. You say that 99239 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says that 99239 is denied because records do not 
include the time spent performing this service, as is required. 
 
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 99239 is hospital inpatient or observation discharge day management; more than 30 minutes on the date 
of the encounter. 
 
We find that CPT code 99239 is supported in the medical record. Specifically, the records for the evaluation 
and management services performed on May 13, 2023, coded as 99239 do include documentation that 90 
minutes were spent on this encounter. Based on this information, we decided that Medicare rules for coverage 
of 99239 have been met. Therefore, we decided that the Plan has to pay for the evaluation and management 
services coded as 99239 performed on May 13, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on May 9, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 procedure code A4239 have been met. 
In this case, no medical records were provided for review after multiple attempts made by the Plan to obtain 
them. Therefore, we decided that the Plan does not have to pay for procedure code A4239 provided on May 9, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx test (0242U) provided on September 
15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the information on your test order is filled 
out to demonstrate the Medicare medical necessity coverage criteria The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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 the Guardant360 CDx test (0242U) provided on 
September 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 30, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 30, 2023.