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

 
We decided that the Plan does not have to pay for the Tissue Cypher Barrett's esophagus assay (0108U) 
provided on December 19, 2022. 
 
You asked the Plan to pay for the Tissue Cypher Barrett's esophagus assay. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Tissue 
Cypher Barrett's esophagus assay have not been demonstrated in the peer-reviewed literature. 
 
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 Tissue Cypher Barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that Tissue Cypher testing is not medically necessary and not standard 
of care. 
 
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 Tissue Cypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tissue Cypher Barrett's esophagus assay (0108U) provided 
on December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tissue Cypher Barrett's esophagus assay (0108U) 
provided on February 20, 2023. 
 
You asked the Plan to pay for the Tissue Cypher Barrett's esophagus assay. You say that the clinical value and 
effectiveness of Tissue Cypher Barrett's esophagus assay have not been demonstrated in the peer-reviewed 
literature. The Plan denied your request. The Plan says this test is a covered Medicare benefit. 
 
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 Tissue Cypher Barrett's esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that Tissue Cypher is not standard of care and 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 Tissue Cypher Barrett's esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tissue Cypher Barrett's esophagus assay (0108U) provided 
on February 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 28, 2022, 
billed with codes 70100, 72040, 70310, 74230. 
 
You asked the Plan to pay for the radiology services. You say that medical records submitted supports Current 
Procedure Code (CPT) codes 70100, 72040, 70310, 74230 and should be paid The Plan denied your request. 
The Plan says The Plan says that POS 11 (office setting) was billed, however, documentation received does not 
support that the services were performed in an office setting but rather in a mobile setting at a skilled nursing 
facility (SNF). 
 
Medicare rules say that for services in a mobile unit, the POS code assigned should either be the POS code for 
the entity the mobile unit is serving, or POS code 15.  
In this case, the CPT Code Manual definition of code 70100, 72040, 70310, 74230 is radiology services of the 
jaw, neck, spine, and teeth. 
 
We find that CPT code 70100, 72040, 70310, 74230 were billed with a POS code 11 (in office). The medical 
records submitted indicates that the radiology services were performed in a mobile setting at a skilled nursing 
facility. Based on this information, we decided that Medicare rules for coverage of the radiology services have 
not been met. Therefore, we decided that the Plan does not have to pay for the radiology services provided on 
December 28, 2022, billed with codes 70100, 72040, 70310, 74230.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SSC test provided on October 17, 2022. 
 
You asked the Plan to pay for the DecisionDx-SSC test. You say that the DecisionDx-SSC test was medically 
necessary. The Plan denied your request. The Plan says the DecisionDx-SSC test is not medically necessary 
and considered non-standard testing. 
 
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 DecisionDx-SSC test. Our reviewer says 
that the requested the DecisionDx-SSC test is not considered medically reasonable and necessary in this case. Our physician reviewer found he DecisionDx-SSC test is not medically necessary and does not meet the 
Medicare coverage criteria. 
 
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 DecisionDx-SSC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SSC test provided on October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infectious disease polymerase chain reaction (PCR) panel 
rendered on December 12, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this testing was not indicated. 
 
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 need for this testing is unclear from the records. 
 
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 an infectious disease polymerase chain reaction (PCR) panel rendered on December 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) visit (73590, 99283) provided on May 
13, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room (ER) visit (73590, 
99283) provided on May 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) 
(43277) provided on March 22, 2023. 
 You asked the Plan to pay for endoscopy. You say that the medical records submitted supports code 43277 and 
should be paid. The Plan denied your request. The Plan says code 43277 is included in Current Procedural 
Terminology (CPT) code 43264; this means, it can't be separately reimbursed. The medical records received do 
not support that the procedure or service was distinct or independent from other services performed; this means 
the use of the 59 modifier 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, we have confirmed that code 43277 is a column II code to column I code 43264; however, 43277 
was billed with a modifier.  
 
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 endoscopy. Our reviewer says that the medical records 
submitted do not support that code 43277-59 was a distinct and separate procedure. Therefore, code 43277-59 
remains 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 endoscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) (43277) provided on March 22, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on March 30, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on March 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram and the digital breast 
tomosynthesis provided on December 9, 2022, by an OON provider.  
 You asked the Plan to pay for the mammogram and breast tomosynthesis. You say that you are appealing the 
denial with supporting documentation. The Plan denied your request. The Plan says these services are not 
covered when received out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan offers a POS option to use either network or out-of-network providers. Certain covered 
services may only be received from network providers. 
 
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 screening mammogram and the digital breast 
tomosynthesis provided on December 9, 2022, by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must have a history of osteoporotic fracture OR has tried and 
failed Zoledronic Acid. 
 
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 Prolia. Our reviewer says that the Plan' 
step therapy criteria have not been met. Our physician reviewer found there is no documentation of an 
osteoporotic fracture. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the administration of ceftriaxone provided during an 
outpatient hospital stay for date of service April 18, 2023, billed with code 96375.  
 
You asked the Plan to pay for the services coded as 96375. You say that this was correctly coded for the 
intravenous injection of ceftriaxone which was ended on April 18, 2023.  The Plan denied your request. The 
Plan says this is not the correct code for the services rendered.  
 
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 96375 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); each additional sequential intravenous push of a new substance/drug (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 96375 is not supported in the medical record. Specifically, the record does not support 
that this was an intravenous push, which is considered to be an injection of less than 15 minutes. In this case, 
the infusion was performed over an hour. There is a more appropriate code to describe this service. Based on 
this information, we decided that Medicare rules for coverage of the services coded as 96375 have not been 
met. Therefore, we decided that the Plan does not have to pay for the administration of ceftriaxone provided 
during an outpatient hospital stay for date of service April 18, 2023, billed with code 96375.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for ultrasound guidance for vascular access (procedure code 76937) 
rendered on April 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 76937-26 remains 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 76937 is "Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access 
sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure)." 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had an endovascular 
procedure, and ultrasound was used for puncture. The report shows that ultrasound was used, and hard copy 
images of the same were saved. The report supports proper documentation of CPT 76937. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
ultrasound guidance for vascular access (procedure code 76937) rendered on April 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies and needle electromyography 
provided on April 18, 2023. 
 
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that you are an 
in-network provider and the claim denied in error. The Plan denied your request. The Plan says 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. This provider is not a network provider with the Plan. We have also determined that these 
services are not urgent or emergent, nor were they approved in advance.  
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nerve conduction studies and needle electromyography provided 
on April 18, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit (99285) provided on March 19, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit (99285) provided on March 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 24, 2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would like the 
copayment to be lower. 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 $195 
copayment per day, for days 1-7, and a $0 copayment per day, for days 8-90, for inpatient hospital care. 
 
 
 You have been asked to pay a $390 copayment for the inpatient hospital stay ($195 copayment x 2 days = 
$390). This item/service falls within the inpatient hospital care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the inpatient hospital stay provided from February 24, 2023, to February 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost-sharing applied to skilled nursing facility (SNF) 
services provided on April 7, 2023, to April 20, 2023. 
 
You asked the Plan to adjust the cost-sharing applied to the SNF services. You say that there were two separate 
SNF stays, one in February and another in April. You say that these seem to have been billed as one continuous 
stay in error. You say that Medicare should pay for two separate stays, and the enrollee's cost-sharing should be 
adjusted.  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). The enrollees contract with the Plan clearly says that enrollees must pay a $196 copayment each day for Medicare-covered days 21 to 45 for Skilled Nursing Facility (SNF) 
Care. The enrollees contract with the Plan also clearly says that a benefit period starts on the first day in a SNF 
and ends when you havent been at any SNF for 60 days in a row.  
 
The records show that the enrollee received SNF services from February 8, 2023, to February 25, 2023. This 
was the first 17 days of the benefit period. Prior to 60 days in a row passing, the enrollee was admitted for 
further SNF care. The SNF services provided on April 4, 2023, to April 20, 2023, are considered a part of the 
same benefit period as the February SNF stay. This means that dates of service April 4, 2023, to April 6, 2023, 
are considered days 18 to 20 of the benefit period.  
 
The enrollee has been asked to pay a total of $2,548 for SNF services provided on April 7, 2023, through April 
20, 2023. These dates of service were considered days 21 to 34 of the benefit period. The enrollee was charged 
a $196 copayment for each of these 13 days. These services fall within the Skilled Nursing Facility (SNF) Care 
benefit category. This means that the enrollee has been asked to pay the correct amounts based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to adjust the cost-sharing applied to skilled nursing facility 
(SNF) services provided on April 7, 2023, to April 20, 2023.