Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 1, 2023. 
 
You asked the Plan to pay for the medical services. You say that the medical records show the necessity of the 
services and payment should be made for an additional unit of service. The Plan denied your request. The Plan 
says you billed this claim with an inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R06.89 and J96.02. Code J96.02 is an Excludes1 code 
under code R06.89, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG+ panel provided on October 28, 2022. 
 
You asked the Plan to pay for the Tempus xG+ panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic.  
 
We looked at the file and Medicare rules. Research shows that the Tempus xG+ is not FDA approved nor does 
it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules 
for coverage of the Tempus xG+ panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the Tempus xG+ panel provided on October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on March 27, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by an out-of-
network provider. 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 Plan contract also says that out-of-network virtual care 
services are not covered. 
 
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 telehealth visit provided on March 27, 2023, 
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records in this case do not document the Intracept procedure is safe and 
effective, not mainly for the convenience of the patient or the physician, not experimental or investigational, is 
appropriate, is furnished in accordance with accepted standards of medical practice for the diagnosis or 
treatment of the patient's condition or to improve the function of a malformed body member, is furnished in a setting appropriate to the patient's medical needs and condition, is ordered and furnished by qualified 
personnel, is one that meets, but does not exceed, the patient's medical need and is at least as beneficial as an 
existing and available medically appropriate alternative as required by the Social Security Act, Section 1862 
(a)1(A) and the 42 CFR Section 411.15(k). 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF Liquid Biopsy CGP Panel (81455) provided 
February 19, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says this test is not 
FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion 
in vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus xF Liquid Biopsy CGP Panel (81455) provided 
February 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 31, 2022, to 
June 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided the required 
NOA. 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 May 31, 2022, to June 
29, 2022.  
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
March 10, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this letter documents the medical necessity of 
the test requested for the enrollee to assist in the treatment, prognosis and diagnosis of their cancer.  The Plan 
denied your request. The Plan says this testing has not been FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a 
companion in vitro diagnostic or an FDA-approved or -cleared indication for use in this cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 30, 2022, to 
November 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim was billed correctly. 
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 October 30, 2022, to 
November 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27520 and 99285 rendered on February 16, 
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 the records do not support the services 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 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 not supported by the medical records. Our reviewer found that in terms of CPT 27520, the 
procedure report does not include sufficient documentation to confirm closed treatment of patellar fracture, 
without manipulation. In this procedure, the provider performs a closed reduction of a knee cap fracture without manipulation. The goal of the procedure is to ensure a stable position of the patella. There is a more 
appropriate code to report for service described. 
 
In terms of CPT 99285, the evaluation and management service provided in the records supports a extended 
focused history; comprehensive exam; and medical decision making of low complexity. There is a more 
appropriate code to report for the level of service documented. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 27520 and 99285 rendered on February 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 70450, 73562, 90471, 90714, and 96372 billed for date 
of service February 3, 2023. 
 You asked the Plan to pay for codes 70450, 73562, 90471, 90714, and 96372. You say that these services were 
medically necessary and provided in good faith. The Plan denied your request. The Plan says the denied codes 
are not separately payable. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
this case, codes 73562, 90471, and 96372 have a status indicator of Q1, meaning that they are STV-packaged 
services.  These disputed codes were billed on the same claim with a code that has a status indicator of S, T, or 
V.  This means that these three codes are not separately payable. 
 
In relation to code 70450, The rules say that outpatient hospital codes that have a status indicator of Q3 are 
considered part of the composite Outpatient Prospective Payment System (OPPS) rate and are not paid 
separately. Code 70450 has a status indicator of Q3, so this code cannot be separately paid. 
 
In relation to code 90714, the rules say that codes that have a status indicator of N are considered packaged 
services and no separate payment is made for these codes. Code 90714 has a status indicator of N, so no 
separate payment can be made for this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 70450, 73562, 90471, 90714, and 96372 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 70450, 73562, 90471, 90714, and 96372 billed for date of service February 
3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April13, 2023, billed with 
codes 87150, 87798, 87481. 
 
You asked the Plan to pay for the genetic testing billed. You say that your laboratory performed all the tests 
that were ordered by the referring physician. 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. 
 We looked at the file and Medicare rules. This was an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April13, 2023, billed with codes 87150, 87798, 87481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 21, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have been going to this provider for a while 
now and this has not been an issue before. You say that you do not believe this should have denied nor should 
you be liable for the full payment if the chiropractic service was covered. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on August 26, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by an out-of-
network provider. 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 Plan contract also says that out-of-network virtual care 
services are not covered. 
 
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 telehealth visit provided on August 26, 2022, 
by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Euflexxa is only covered for certain indications. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested injections are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a history of left knee pain due to osteoarthritis of the left knee. The 
enrollee has been treated with knee bracing, medication, topical ointments and corticosteroid injections. records 
do not show failure of three months of conservative therapy. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung 
cancer screening (71271) provided on April 7, 2023. 
 
You asked the Plan to pay for the LDCT scan. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the service provided.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the case file and Medicare rules. Based on this information, we find that the enrollee does not 
meet Medicare criteria for coverage of this service. Specifically, the rules say that Medicare covers one annual 
LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, we 
decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung cancer 
screening (71271) provided on April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric scooter you purchased on February 16, 2023. 
 
You asked the Plan to pay for the electric scooter. You say that you need this scooter because you have severe 
mobility limitations.  The Plan denied your request. The Plan says you have not had the required home 
assessment in order to approve this item. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a scooter to be covered, the patient 
must undergo an in-home assessment to determine the appropriateness of the item.  In this case, there is no 
evidence that you had an in-home assessment prior to purchasing the scooter at issue. We looked at the file and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electric scooter 
have not been met. Therefore, we decided that the Plan does not have to pay for the electric scooter you 
purchased on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on August 26, 2022, by an OON 
provider.  
 You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received from an out-of-
network provider. 
 
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 Plan contract also says that out-of-network virtual care 
services are not covered. 
 
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 telehealth visit provided on August 26, 2022, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on April 03, 
2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you received a 
mammogram, not an ultrasound. 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 $100 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $100 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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. The medical records show an ultrasound was provided on April 3, 
2023. Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound 
provided on April 03, 2023.