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

 
We decided that the Plan does not have to pay for the genetic testing for nail pathogens provided on May 24, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is paid by Medicare and was 
medically necessary. The Plan denied your request. The Plan says a review of the medical literature and clinical 
practice guidelines do 
not support this testing as a first line approach for evaluation of nail infections and it is not widely accepted as 
standard of care. 
 
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 genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current standard of care for investigation of onychomycosis in a toenail is to perform a 
potassium hydroxide (KOH) and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollees nail specimen required genetic testing when other less 
expensive and efficacious lab tests (KOH and fungal culture) are available. Therefore, this genetic testing of 
this enrollees toenail was not medically reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing for nail pathogens provided on May 24, 2022.
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 is already in a hospital 
setting and it would be at a high risk of catching infections needed to wait over 30 days for approval and 
transfer. The Plan denied your request. The Plan says the enrollee's records do not show the need for continued 
treatments and care that can only be given in a hospital setting. Care is being met at the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service February 28, 
2022 to March 1, 2022. 
 
You asked the Plan to pay for procedure code S9338. You say that this service was medically necessary. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service February 28, 2022 to March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you need the power scooter as soon as 
possible due to mobility issues. The Plan denied your request. The Plan says this request is not medically 
necessary. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
Medicare rules also say that the supplier or practitioner must perform an on-site evaluation of the beneficiarys 
home to verify that the beneficiary can adequately maneuver the device that is provided considering physical 
layout, doorway width, doorway thresholds, and surfaces. 
 
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 power scooter. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the documentation does not indicate 
that the requested PMD will fit safely in your home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81226) provided on April 
12, 2023. 
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that this test informs the clinicians 
about which medication may require dose adjustment, may be less likely to work, or may have an increased 
risk of side effects based on a patients genetic makeup. The Plan denied your request. The Plan says the 
GeneSight Psychotropic has not been shown to be useful, is not considered medically necessary and 
appropriate, and is not covered by Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered when the 
criteria in the rules section of this letter 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 pay for the GeneSight Psychotropic test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that individual genes 
have been shown to be associated with risk of psychiatric disorders and specific aspects of psychiatric drug 
treatment such as drug metabolism, treatment response, and risk of adverse effects. Commercially available 
testing panels include several of these genes and are intended to aid in the diagnosis and treatment of mental 
health disorders. GeneSight Psychotropic gene panel testing is considered not medically necessary as the 
evidence is insufficient to determine the effects of the technology on health outcomes. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for the GeneSight Psychotropic test (81226) provided on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service April 19, 
2023. 
 You asked the Plan to pay for procedure code 99222. You say that 99222 is eligible for payment because the 
enrollee saw multiple specialists on the same date of service. The Plan denied your request. The Plan says 
payment for code 99222 is bundled into payment for code 93016. 
 
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 99222 
is a column II code to column I code 93016. Both codes were billed by a physician of the same specialty in the 
same group, which is considered the same provider. This claim has not been billed with an appropriate modifier 
to bypass the edit. 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 code 99222 billed for date of service April 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of needle or intracatheter, upper or lower 
extremity artery (36140) provided on January 14, 2023. 
 
You asked the Plan to pay for the introduction of needle or intracatheter, upper or lower extremity artery. You 
say that this service was medically necessary. The Plan denied your request. The Plan says the medical records 
indicate that arterial line placement was performed. There is a more appropriate Current Procedural 
Terminology (CPT) code that should be used to bill for the service provided. 
 
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 36140 is the introduction of needle or intracatheter, upper 
or lower extremity artery. 
 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 introduction of needle or intracatheter, upper or lower 
extremity artery. Our reviewer says that coverage criteria are not met for code 36140. Our reviewer found that 
the medical records do not support the use of procedure 36140 as there is a more specific procedure code to 
capture the introduction preformed. 
 
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 introduction of needle or intracatheter, upper or lower extremity artery have 
not been met. Therefore, we decided that the Plan does not have to pay for the introduction of needle or 
intracatheter, upper or lower extremity artery (36140) provided on January 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 4, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the records do not 
include an order that specifically list what test(s) are to be performed in the custom panel. 
 
The Plan must follow Medicare rules. Medicare rules say that "the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the provided testing. The documentation also does not contain medical records 
showing the ordering physicians intent that the requested testing be performed. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the testing provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 23, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed date of 
service 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. 
 
We find that payment for CPT code 0018U and 81445 is not supported in the medical record. Specifically, the 
records show that the specimen was collected on September 12, 2022. As such, the billed date of service is not 
supported. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 
23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested bone marrow aspirate is not medically reasonable or 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for fluoroscopic guidance provided on April 13, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that experimental or investigational services are not covered. 
 
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 provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for fluoroscopic guidance 
provided on April 13, 2021.  
 
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 the Group 3 power wheelchair multiple power option 
(K0861) electronic connection (E2311) expandable controller (E2377) and expandable controller harness 
(E2313). 
 
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that please review 
the attached medical documentation to support the need of the custom medical equipment being requested. The 
Plan denied your request. The Plan says the enrollee does not have medical need for multiple power options 
included with K0861 group 3 power wheelchair. The upgraded electronics cannot be covered as it is not 
medically necessary to control the three requested power options through the joystick  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 power wheelchair and upgraded 
electronics. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing basic daily activities. The enrollee cannot propel a manual wheelchair 
or operate a power scooter and cannot perform pressure relief independently due to upper extremity weakness 
and requires a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The 
enrollee requires power elevating leg rests for positioning of their lower extremities and lower extremity 
edema. The complexity of the enrollees seating and positioning needs necessitates a more complex group 3 
power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the three power options via a joystick. These components are 
required to operate 3 or more power options on a group 3 power wheelchair. Therefore, the expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311) is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair and upgraded electronics have been met. Therefore, we 
decided that the Plan does not have to pre-approve the Group 3 power wheelchair multiple power option 
(K0861) electronic connection (E2311) expandable controller (E2377) and expandable controller harness 
(E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #14 provided on February 4, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you were told all the dental services would be 
covered. The Plan denied your request. The Plan says the denial of payment for the crown was correct, because 
the x-rays provided it is unclear what the enrollee's current oral condition was. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says that the 
crown does not meet the criteria for coverage. Our physician reviewer found that the documentation indicates 
that tooth #14 does not appear to have significant coronal breakdown to warrant a crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pay for a crown (D2740) for tooth #14 provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you must use network providers for health services and items. This service is 
available by a provider in your network. 
 
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 
an office visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (87340, A4657, 82310, 82040) provided on 
February 1, 2023 to February 28, 2023. 
 
You asked the Plan to pay for the dialysis services. You say that this service was 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 codes 87340, A4657, 82310, & 82040 are not supported in the medical record. Specifically, 
the claim did not include appropriate value codes, amounts, and occurrence codes. Based on this information, 
we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided 
that the Plan does not have to pay for dialysis services (87340, A4657, 82310, 82040) provided on February 1, 
2023 to February 28, 2023.