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

 
We decided that the Plan has to pre-approve a targeted genomic sequence analysis panel. 
 
You asked the Plan to pre-approve a targeted genomic sequence analysis panel. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that NGS 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 a targeted genomic sequence analysis 
panel. Our reviewer says that the services are medically necessary. Our physician reviewer found the review 
indicates that the enrollee is a 65-year-old female with a history of Lung and Endometrial cancer with a new 
brain lesions. The review has determined that the enrollee meets the coverage criteria detailed in the NCD. 
 
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 targeted genomic sequence analysis panel have been met. Therefore, we 
decided that the Plan has to pre-approve a targeted genomic sequence analysis panel.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 You asked the Plan to pre-approve the power seat elevation feature. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says that a power seat elevation feature does not 
serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment; methadone (G2067) 
provided November 12, 2022. 
 
You asked the Plan to pay for medication treatment. You say that the facility has been enrolled in the Medicare 
program to provide OTP services since January 1, 2020. The Plan denied your request. The Plan says this 
provider was not certified/eligible to be paid for this procedure/service on this date of service. 
 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 G2067 is medication assisted treatment, methadone; 
weekly bundle including dispensing and/or administration, substance use counseling, individual and group 
therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment 
program). 
 
We find that CPT code G2067 is not supported in the medical record. Specifically, the claim for G2067 was 
billed by the rendering provider, not the OTP facility. According to policy, individual providers cannot bill 
HCPCS code G2067. This code must be billed by the OTP facility in their facility claim. Based on this 
information, we decided that Medicare rules for coverage of medication treatment have not been met. 
Therefore, we decided that the Plan does not have to pay for the medication assisted treatment; methadone 
(G2067) provided November 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
14, 2022, through November 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided records in this case do not document that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 14, 2022, through 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 77014 billed for date of service December 15, 2022. 
 
You asked the Plan to pay for code 77014. You say that this service should be covered. The Plan denied your 
request. The Plan has provided no definitive argument for its denial. 
 
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 case file that the Plan sent us is exceedingly poor and missing key pieces of 
information.  It is missing any specific rationale for denial, any specific copies of notices of denial that may 
have been issued that would provide such rationale, and it is missing any analysis of the facts of the case.  In 
fact, the case file submitted to us was so poor and lacking in information that we had to reach out to the Plan to 
even ascertain what dates of service were even in question.  After we received the Plan's response, we were 
able to confirm that you have only completed a Waiver of Liability for this one specific date of service, so our 
jurisdiction to review this issue is limited to that.  You will need to contact the Plan directly if you wish to 
appeal further items/services. 
 
As noted, the Plan has failed to supply information needed to make an assessment as to whether or not the 
Plan's denial was appropriate.  The burden is on the Plan to show why its denial is correct.  Due to its failure to 
supply the above-mentioned information, we find that the Plan has not met this burden. Therefore, we decided 
that the Plan has to pay for code 77014 billed for date of service December 15, 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J1097 for date of service October 6, 2022. 
 
You asked the Plan to pay for code J1097. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the code billed is not payable. 
 
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 J1097 is phenylephrine 10.16 mg/ml and ketorolac 2.88 
mg/ml ophthalmic irrigation solution, 1 ml. 
 
We find that CPT code J1097 is not supported in the medical record. Specifically, code J1097 has a status 
indicator of "N". A status indicator of N means that payment is packaged into other services. No separate 
payment can be made as billed. Based on this information, we decided that Medicare rules for coverage of code J1097 have not been met. Therefore, we decided that the Plan does not have to pay for code J1097 for date of 
service October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a POV. 
 
You asked the Plan to pre-approve a POV. You say that a power chair is needed to complete activities outside 
your house. The Plan denied your request. The Plan says that the requested POV is not covered for outside use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a POV.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0667, E0673) provided November 23, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that this enrollee has 
had great need of DVT prevention during the non-ambulatory recovery period. It is necessary in the enrollee's 
recovery after surgery. The Plan denied your request. The Plan says pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0667, E0673) 
provided November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87636 billed for date of service January 19, 
2023. 
 
You asked the Plan to pay for procedure code 87636. You say that the services at issue are billed correctly. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87636 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87636 billed 
for date of service January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is allowed and payable. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation One CDx (F1CDx) testing provided on 
October 6, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not show that the enrollee has 
advanced, metastatic, recurrent or refractory cancer. 
 
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. Complete medical records from the treating physician are needed to 
determine the medical necessity of why the large number of genes were tested or how they will impact the 
enrollee's care. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of the F1CDx testing have been met.  Therefore, we decided that the 
Plan does not have to pay for the Foundation One CDx (F1CDx) testing provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95927, 95955, 95908, 95885) provided on April 
21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 95927, 
95955, 95908, and 95885, is not supported by the records provided. Our reviewer found that for code 95927, 
the record does not contain evidence that somatosensory evoked potential study (SSEP) was performed with 
recordings in the trunk and head. There is a more specific code for the SSEP procedures performed. For code 95955, the record does not contain evidence that a diagnostic electroencephalogram (EEG) was performed 
during surgery. The record shows that the EEG was for intraoperative neuromonitoring only, which is included 
in intraoperative neuromonitoring services and is not separately reportable. For code 95908, the record states 
that the nerve conduction studies were performed to monitor responsiveness under anesthesia, not as a full 
diagnostic procedure. There is a more specific code for intraoperative neuromonitoring. For code 95885, the 
record does not contain evidence that needle electromyography (EMG) with nerve conduction, amplitude and 
latency/velocity study was performed. The record supports free running EMG as part of intraoperative 
neuromonitoring. 
 
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 the services (95927, 95955, 95908, 95885) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on October 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that the provider was not aware they were out-of-
network. The Plan denied your request. The Plan says this was not authorized. 
 
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 podiatry services provided on October 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on September 30, 2021. 
 
You asked the Plan to pay for practitioner visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the Plan is the secondary payer for this enrollee so is not responsible 
for payment until the primary payer payment information is received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you 
to submit the bill to the enrollees primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for practitioner visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for a practitioner visit provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider at the in-network benefit level. 
 
You asked the Plan to pre-approve OON pain management services at the in-network benefit level. You say 
that this should be covered as in-network. The Plan denied your request. The Plan says this is covered under the 
enrollee's out-of-network Point-of-Service (benefit). 
 
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 at the in-network benefit level 
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 at the in-network benefit level. Therefore, we decided that the Plan 
does not have to pre-approve pain management services to be provided by an out-of-network (OON) provider 
at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes K0861 and E1028 provided on May 22, 2022. 
 
You asked the Plan to pay for procedure codes K0861 and E1028. You say that the denied procedure codes 
were medically necessary and are supported in the medical records. The Plan denied your request. The Plan 
says that the claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported their denial. The record indicates that 
the power wheelchair was paid at the Medicare allowed rate, but no payment is reflected. Additionally, the 
record indicates that procedure code E1028 has a medically unlikely edit (MUE) of 6. The provided 
documentation does not support the Plan's denial that procedure code E1028 at issue exceeds the maximum 
number of services allowed under the guidelines for a single date of service. Therefore, we decided that the 
Plan has to pay for procedure codes K0861 and E1028 provided on May 22, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service November 
12, 2022. 
 
You asked the Plan to pay for procedure code 99255. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service November 12, 2022.