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

 
We decided that the Plan does not have to pay for the Shingles vaccine and administration provided on 
December 2, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you called to make sure you could get the test. 
The Plan denied your request. The Plan says these services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine and administration 
provided on December 2, 2022.  
 
Benefits for the vaccine services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38900, 38525, & 11606 provided on April 
19, 2023. 
 
You asked the Plan to pay for procedure codes 38900, 38525, & 11606. You say that these services were 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 38525 & 11606. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Code 38900 is an add-on code. Since the primary code is not 
covered, the add-on code cannot be covered. Based upon this information, we find that Medicare coverage criteria for procedure codes 38900, 38525, & 11606 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 38900, 38525, & 11606 provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit (99213) provided on June 
15, 2023. 
 
You asked the Plan to waive the cost sharing for the outpatient service. You say that you have never had to pay 
for medical facilities except for the deductible. You also say that you do not feel you should have to pay this 
bill. 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 $50 
copayment for Outpatient hospital services.  
 
You have been asked to pay $50 copayment for the outpatient service. This service falls within the Outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the office visit 
(99213) provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 11, 2023, billed with 
codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 You asked the Plan to pay for the genetic testing billed. You say that documentation was provided for review. 
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. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single 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 July 11, 2023, billed with codes 87150, 87481, 87641, 87653, 
87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on 
April 26, 2023. 
 
You asked the Plan to pay for the positron emission tomography (PET) scan. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the positron emission 
tomography (PET) scan provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that you strongly recommend non-invasive 
ventilation (NIV) be approved for the patient. You also say that without NIV therapy, the patient is at high risk 
for hospital readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in targeted tidal volume, volume-assured pressure support 
mode with Auto-expiratory positive airway pressure (EPAP) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
patient has chronic respiratory failure from COPD. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. Our reviewer also 
found that the patient could be treated with a BiPAP machine with average volume-assured pressure support 
(AVAPS) capability and failure of such a device has not been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet all the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower level of 
care. 
 
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 the enrollee's needs can be met at a lower level of care and do not rise to the level of 
LTACH admission.  
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 an office visit provided on May 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
May 31, 2023.  
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that these are covered services 
which were performed by an accredited laboratory. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87481 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. The MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 
19 units of this code, exceeding the MUE. You did not provide all the required evidence showing that the 
excess units were actually provided, were correctly coded, and were medically necessary. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87481 and 87798 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for 
date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service June 7, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that 22 
or more drug classes were tested. The records do not show that the treating physician ordered testing of 22 or 
more specific drug classes based on clinical history and risk assessment. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0483 billed for date of service June 7, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris (J1300). 
 You asked the Plan to pre-approve Soliris. You say that you have tried other infusions and they have not 
worked. You also say that this is a new one that your doctor wants you to try. The Plan denied your request. 
The Plan says based on the submitted documentation you do not meet the Medicare Preferred criteria. 
 
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 Soliris. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Ultomiris 
before they will approve the requested drug. In this case, you have not tried and failed the required drug. Our 
reviewer also found that there is no documentation provided indicating that the Plan's required drug would 
likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Soliris (J1300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on July 
18, 2022. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that you should not be 
responsible for the coinsurance. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the wound care supplies. This item/service falls within the 
durable medical equipment and related supplies 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 total amount you owe is $81.61 ($401.54 allowed amount x 
20% = $81.61). Therefore, we decided that the Plan does not have to waive the coinsurance for the wound care 
supplies provided on July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81518 billed for date of service June 20, 2023. 
 
You asked the Plan to pay for code 81518. You say that this testing was performed on a stored specimen. The 
Plan denied your request. The Plan says the medical records do not support the billing of code 81518. There is 
a discrepancy between the date of specimen collection and the date of service 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. 
 
 In this case, the CPT Code Manual definition of code 81518 is Oncology (breast), mRNA, gene expression 
profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-
embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit 
from extended endocrine therapy. 
 
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 code 81518. Our reviewer says that code 81518 is not 
supported by the medical record. Our reviewer found there is no documentation or lab order to support the 
billing of this code.  
 
In addition, you billed this lab service with date of service June 20, 2023. According to your appeal letter, this 
lab service was performed on a very old stored specimen.  Under Medicare rules, that means that the date of 
service would need to equal the date that the specimen was collected from storage. Unfortunately, it appears as 
though you billed the date of service as the date that the lab test was performed (not the date when the 
specimen was collected from storage), which does not conform with Medicare billing rules for stored 
specimens. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 81518 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 81518 billed for date of service June 20, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on November 10, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that this denial is appropriate given the enrollee's clinical scenario. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
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 did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
genetic testing provided on November 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 units of code 87481 billed for date of service December 27, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 the 
records provided do not support 5 units of code 87481. Our physician reviewer found that the records contain 
results for 4 candida species, which equals 4 units. 
 
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. Therefore, we decided that the Plan does not 
have to pay for 5 units of code 87481 billed for date of service December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the records to be reviewed 
showing the patient is using and benefiting from the ventilator. The Plan denied your request. The Plan says the 
request for continued coverage of a home mechanical ventilator that is not being used by the patient is not 
covered. 
 
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.  
 
 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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
patient has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. Our reviewer also found that the patient could be treated with a BiPAP machine with 
average volume-assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you did not see a claim mail by date on the 
paperwork and you would have gotten the claims if you knew there was a deadline. You say that you are trying 
to salvage some expenses that could be covered. The Plan denied your request. The Plan says the claim was 
submitted past the deadline for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dental services have not been met. Specifically, the Evidence of Coverage states Pick Your 
Perks expenses must be submitted by March 31, 2023. This claim was submitted past that deadline and is not 
eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for dental services 
provided on December 12, 2022.