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

 
We decided that the Plan does not have to pay for the Tempus xT comprehensive genomic profiling testing 
(81456) provided on June 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that the Tempus RNA sequencing part of the 
Tempus xT comprehensive genomic profiling testing offered is medically necessary and therefore should be 
paid. The Plan denied your request. The Plan says this test is not covered by Medicare. 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 Tempus xT comprehensive genomic profiling 
testing (81456) provided on June 15, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87491 billed for date of service 
July 6, 2023. 
 
You asked the Plan to pay for procedure codes 87640 and 87491. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 
87641. Code 87491 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 87640 
is a column II code to column I code 87641. While code 87640 was billed with modifier -59, the medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service. The 
documentation submitted did not include a physician order or laboratory requisition for the billed test 
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique; 
therefore, code 87491 is not supported. 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 codes 87640 and 87491 billed for 
date of service July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 25, 2022, billed 
with procedure code 99309. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the records from this date describe the 
enrollee with chronic conditions, and homebound. However, the history and physical were each not detailed, 
nor the medical decision-making of moderate complexity as the patient did not have a significant new issue or 
require workup or significant changes in the treatment plan. Therefore, the code, 99309 is not sufficiently 
supported in the documentation.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 25, 2022, billed with procedure code 
99309.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by code 99232 billed on date of service February 27, 2023.  
 
You asked the Plan to pay for 99232. You say that 99232 should be paid as billed because it is supported in the 
documentation and was performed by an inpatient physican. The Plan denied your request. The Plan says 
99232 is denied because it was billed with an incorrect place of service (POS).  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that E&M services provided 
to enrollees residing in a SNF or NF must be reported using the appropriate CPT level of service code within 
the range identified for Initial Nursing Facility Care and Subsequent Nursing Facility Care. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, we have confirmed that 
99232 is a hospital inpatient or observation care code. In this case, 99232 was billed with POS 31, indicating 
the services took place at a SNF. The record also supports the E&M services described by code 99232 were 
performed at a SNF and not in a hospital setting. Per Medicare rules, E&M services provided to enrollees 
residing in a SNF on the date of service must be reported with either Initial Nursing Facility Care codes or 
Subsequent Nursing Facility Care codes. Based on this information, we decided that Medicare rules for 
coverage of 99232 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management (E&M) services described by code 99232 billed on date of service February 27, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of care with an out-of-network (OON) 
ophthalmologist. 
 
You asked the Plan to pre-approve the continuation of care with an OON ophthalmologist. You say that the 
requested OON provider is a nationally and internationally recognized expertise in the field of diseases of the 
eye. You say that it is frightening to consider being a victim to partial or permanent blindness, as many 
members of your family have become. You say that you have a strong patient/doctor rapport with the requested 
OON provider, and that your continuity of care would be disrupted if forced to change to a new provider. The 
Plan denied your request. The Plan says that they cannot find a medically necessary reason why the needed 
services could not be performed by an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. Medicare rules also 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. 
 
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 continuation of care with an OON 
ophthalmologist. Our reviewer says that the criteria for coverage of OON care have been met. Our physician 
reviewer found the Plan did not name any specific network ophthalmologists who were fellowship-trained in 
the specialty of glaucoma. While the Plan did mention that there are board-certified ophthalmologists, the 
enrollee's extensive glaucoma eye disease requires close monitoring and an ophthalmologist with a fellowship-
trained specialty in glaucoma is medically necessary. The enrollee is receiving active treatment and appears to 
be very stable on current medication regimen. No lasers, procedures, or surgeries have been recommended in 
the near future. However, the enrollee does have hypotony without maculopathy in the right eye and should be 
followed by fellowship-trained glaucoma ophthalmologists who are more capable to follow and/or treat if 
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 continuation of care with an OON ophthalmologist have been met. 
Therefore, we decided that the Plan has to pre-approve a continuation of care with an out-of-network (OON) 
ophthalmologist.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Quviviq. 
 
You asked the Plan to pre-approve the medication. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Quviviq.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay on May 12, 
2023, to May 26, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with 
the amount charged. 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 $275 
copayment per day for days 1-6 per Medicare-covered stay and after the 6th day the plan pays 100% of the 
covered expenses. For the service it's, $275 x 4 = $1,100. The reduced amount of $460.60 cost share applied to 
the claim due to the out-of-pocket maximum met with this claim. Therefore, results in the total cost sharing 
amount of $460.60.  
 
You have been asked to pay a $460.60 cost share for the inpatient hospital stay. 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 on May 12, 2023, to May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit at a tertiary care center. 
 
You asked the Plan to pre-approve an office visit at a tertiary care center. You say that the service is necessary. 
The Plan denied your request. The Plan says the service can be rendered in a community level setting. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit at a tertiary care center have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an office visit at a tertiary care center.
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 the enrollee requires increased medical 
care in an LTACH. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can safely receive services in the current hospital 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 at the time of the request for LTACH services, the enrollee's status is critical. The 
enrollee is maintained on Norepinephrine and Dobutamine drips. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
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: Outpatient Therapies
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for procedure codes 20931, 22551, 22552, 22845, and 22852 
provided on January 3, 2023 to January 4, 2023. 
 
You asked the Plan to pay for procedure codes 20931, 22551, 22552, 22845, and 22852. You say that these 
services were 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 20931, 22551, 22552, 22845, and 22852 is not supported in the medical record. 
Specifically, the codes billed have status indicators of ."N" and "J1" are not separately payable. Payment for 
these services is always packaged in payment for another service. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 20931, 22551, 22552, 22845, and 22852 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 20931, 22551, 22552, 22845, and 
22852 provided on January 3, 2023 to January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kinova Jaco 2 robotic arm and hand and controller 
activated lift arm switch system (E1399). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are necessary for the enrollee. 
The Plan denied your request. The Plan says the requested devices are not medically necessary as further 
research is needed per the peer-reviewed published scientific medical 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 pre-approve prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has suffered a cervical spinal cord injury and is dependent with mobility, transfers, 
and most of his daily activities, including feeding, dressing, and grooming. It is understandable that the 
requested robotic arm device is being requested. However, there is a lack of medical literature supporting this 
device in terms of significantly improving overall function. The studies have very few participants and are 
limited. It is noted to improve his level of function with feeding and dressing, but this does not mean that it is 
as beneficial as an existing and available medically appropriate alternative. The enrollee is currently receiving 
caregiver assistance with all his daily activities. Therefore, the Kinova Jaco 2 robotic arm and hand and 
controller activated lift arm switch system (E1399) cannot be considered 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Kinova Jaco 2 robotic arm and hand and controller activated lift arm switch system 
(E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records document that the enrollee has 4-/5 right upper extremity strength and 
is independent with feeding (and toileting, per an evaluation from 02/16/2023) thus indicating she has adequate 
upper extremity strength and function to operate the wheelchairs power options with their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 10, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab panel 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 panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. 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 ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).