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

 
We decided that the Plan does not have to pay for procedure codes 71046, 71275, 93306, 93005, 93005-76, 
93005-77, 96374-59, and 94640 billed for May 30, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the outpatient facility rate. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that an OPPS 
payment status indicator is assigned to every HCPCS code. 
 
We looked at the file and Medicare rules. The billed procedure codes have OPPS status indicators that do not 
allow separate payment when billed with approved code 99283. Therefore, we decided that the Plan does not 
have to pay for procedure codes 71046, 71275, 93306, 93005, 93005-76, 93005-77, 96374-59, and 94640 
billed for May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power option (K0862) and additional items and accessories (codes E0953, E0955, E1007, E1012, E1028, 
E2311, E2313, E2359, E2377, E2620, E2624, and K0108).  
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and additional items and 
accessories. You say that the requested power wheelchair is medically necessary. The Plan denied your request. 
The Plan says the notes do not show that the enrollee has a medical need for these power options. The Plan also 
says upgraded electronics (expandable controller, harness, and electronics) cannot be covered per Medicare 
rules. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0862) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has used a power wheelchair since their stroke in 2016. 
The enrollee has intact skin and the capacity to drive a wheelchair with standard controls. Our reviewer also 
found that the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing power drive. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 heavy duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty 
power wheelchair with multiple power option (K0862) and additional items and accessories (codes E0953, 
E0955, E1007, E1012, E1028, E2311, E2313, E2359, E2377, E2620, E2624, and K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testim 1% gel. 
 
You asked the Plan to pre-approve the medication. You say that the medication is 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 Testim 1% gel.   
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the maxillofacial, 
radiologic examination (x-ray) of the knee, and diagnostic injection billed with codes 70486, 73562, and 96372 
provided on December 31, 2022. 
 
You asked the Plan to pay for the exams and injection. You say that codes 70486, 73562, and 96372 were 
billed correctly and should be paid. The Plan denied your request. The Plan says CPT codes 70486, 73562, and 
96372 cannot be billed separately because they are all packaged into payment for CPT codes 99284 and 70450. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 70486, 73562, and 96372 are not supported in the medical record. Specifically, codes 
73562 and 96372 have a status indicator of Q1 and 70486 has a Q3 status in the Outpatient Prospective Payment System (OPPS). Q1 codes are packaged and are not separately paid when billed with another code 
with an OPPS indicator of S, T, or V. In this case, codes 99284 and 70450 that were billed and paid on the 
same date of service have a status of V, and Q3. Therefore, codes 73562, and 96372 are not separately paid. Q3 
codes are paid with a composite rate with other Q3 codes. The composite payment was made on the 70450 
code and there is no separate payment for 70486. Based on this information, we decided that Medicare rules for 
coverage of the exams and injection. have not been met. Therefore, we decided that the Plan does not have to 
pay for the computed tomography (CT scan) of the maxillofacial, radiologic examination (x-ray) of the knee, 
and diagnostic injection billed with codes 70486, 73562, and 96372 provided on December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81479) provided October 
31, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the claim denied as not medically necessary. 
This decision is incorrect, based on current publications and medical practice. The Plan denied your request. 
The Plan says this test is not covered by Medicare.  
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. Per Dex Diagnostics, this test is not covered by Medicare. GeneSight 
Psychotropic is a combinatorial pharmacogenomic test and per the LCD is therefore considered not medically 
necessary. 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 GeneSight Psychotropic test 
(81479) provided October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, for 15-21 drug classes (G0482) 
provided April 14, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that as per the medical record and Centers for 
Medicare & Medicaid Services (CMS) policy guidelines, the billed diagnosis is appropriate  The Plan denied 
your request. The Plan says under Medicare rules, the number of definitive urine drug classes requested are 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the results of the urine drug screen, extensive testing to identify individual 
drugs was performed that were unnecessary.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, for 15-21 drug classes (G0482) provided April 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin Hylecta. 
 You asked the Plan to pre-approve Herceptin Hylecta. 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. 
 
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 Herceptin Hylecta. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herceptin Hylecta have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Herceptin Hylecta.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
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 the medication. Our reviewer says that 
the criteria for coverage of Injectafer have not been met. Our physician reviewer found that the Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs 
would likely be less effective 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transesophageal echocardiogram (TEE). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TEE is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of coronary 
disease and previous coronary angioplasty. He has exertional dyspnea and a previous radionuclide stress test in 
September of 2023 showed an ejection fraction of 45 percent. Transthoracic echocardiogram in 2022 showed 
normal left ventricle systolic function. The clinical guidelines do not support TEE in this setting. The records 
do not support that the criteria for coverage are met; therefore, the TEE is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transesophageal echocardiogram (TEE).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kyphoplasty procedure (22515, 22514). 
 
You asked the Plan to pre-approve the Kyphoplasty procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that percutaneous kyphoplasty (PKP) is covered when 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Kyphoplasty procedure. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the records do not 
show a trial and failure of non-surgical treatments such as fracture bracing. 
 
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 Kyphoplasty procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Kyphoplasty procedure (22515, 22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drug. 
 
You asked the Plan to pre-approve the medication. 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 the self-administered drug.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on May 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive genomic profiling test rendered on 
February 17, 2023. 
 
You asked the Plan to pay for the services. You say that the testing was medically necessary. The Plan denied 
your request. The Plan says the provider was not participating and did not request authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider at issue in this case is not a network provider with the Plan. 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  Our physician reviewer found  
 
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.  
 
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 pay for the services. Therefore, we decided that the Plan does not 
have to pay for a comprehensive genomic profiling test rendered on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99217 and 99225 performed from 
September 4, 2022, to September 5, 2022. 
 
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 services are not supported without the required documentation. 
 
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 the denied codes is: 
 
CPT 99217: 
 
Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial 
date of "observation status." To report services to a patient designated as "observation status" or "inpatient 
status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including 
Admission and Discharge Services, 99234-99236 as appropriate.]) 
 
CPT 99225: 
 
Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 
of these 3 key components: An expanded problem focused interval history; An expanded problem focused 
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 is responding inadequately to 
therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the 
patient's hospital floor or unit 
 
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 the medical record only includes 
"addendums." A procedure report for this date of service was not found. 
 
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 99217 and 99225 performed from September 4, 2022, to September 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on June 13, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says that the current 
documentation doesn't include the method of testing. 
 
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. The Plan argues that the current documentation doesn't include the method of 
testing. The Plan indicates in the case file that records were received from the non-contract provider, but the 
Plan has not provided these records for review. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the drug testing provided on June 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on December 5, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary.  
The Plan denied your request. The Plan says that the diagnosis codes on the claim do not support the billed 
procedure code. 
 
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. The available records do not specify which eye had the cataract nor 
which was treated by the eye surgeon, meaning that the unspecified side code is supported. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have been met. Therefore, 
we decided that the Plan has to pay for the anesthesia services provided on December 5, 2022.  
 
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.