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

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 11, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
May 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on June 5, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99285-25 remains 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. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 emergency room services (procedure code 99285) rendered on June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 15, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 5, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services described by code 64447 performed on 
date of service May 23, 2023. 
 
You asked the Plan to pay for 64447. You say that 64447 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 64447 is denied because it is not supported in the 
documentation and was billed on the same date as code 01402. 
 
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 64447 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, including imaging guidance, when performed.  
 
We find that CPT code 64447 is not supported in the medical record. Specifically, while the provided 
documentation indicates that that a post procedural injection was planned, there is no documentation that an 
injection for management of pain was actually performed. Based on this information, we decided that Medicare 
rules for coverage of 64447 have not been met. Therefore, we decided that the Plan does not have to pay for the 
injection services described by code 64447 performed on date of service May 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 You asked the Plan to pre-approve Udenyca. 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 Udenyca. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 22, 2023, to 
May 26, 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 from 
May 22, 2023, to May 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the integrated biopsychosocial assessment (90791) provided 
July 28, 2023.  
 
You asked the Plan to pay for the behavioral health services. You say that you are unable to do Medicare, but 
you are an active, in-network provider. The Plan denied your request. The Plan says the services were rendered 
by a provider that is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the integrated biopsychosocial 
assessment (90791) provided July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is not under contract with the Health Plan and 
is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on June 26, 2023. 
 
You asked the Plan to pay for annual wellness visit. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you had annual wellness visit on May 1, 2023. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for annual wellness visit provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 16, 2023, billed with 
codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that based on the information provided and the 
physician's decision to order the test, you are requesting coverage at this time for the claim. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Also, Per DEX Diagnostics, the Invitae Arrhythmia and Cardiomyopathy Comprehensive Panel is 
noncovered by Medicare. 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 June 16, 2023, billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 
81403, 81400.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the additional 
PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has been receiving PT. One PT progress note is provided 
and indicates that the enrollee continues to have low back pain with 4/5 motor strength in the lower extremities 
and normal sensation. There is no documentation of continued progress with PT with objective measures, 
including motor strength and range of motion and level of function. The enrollee can continue with a home 
exercise program. Therefore, the 12 additional PT visits are not 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 27, 2023, billed with 
procedure code 99214-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is included in payment of the surgical 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 We looked at the file and Medicare rules. Documentation does not support that a significant, separately 
identifiable service was performed. Based on this information, we decided that Medicare rules for coverage of 
the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for practitioner services provided on March 27, 2023, billed with procedure code 99214-25.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0453-XU rendered on May 11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Healthcare Common Procedure Coding System (HCPCS) code G0453-XU (6 Units) 
remains 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. In this case, the CPT Code Manual definition of 
code G0453 is "Continuous intraoperative neurophysiology monitoring, from outside the operating room 
(remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition 
to primary procedure)." 
 
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 supported by the medical records. Our reviewer found that in this case, the procedure report 
indicates that multiple modalities were monitored during the course of the procedure. In this context, it's 
appropriate to bill for G0453 as a separate procedure for intraoperative neuromonitoring (IONM). This is a 
standard of billing in IONM. Therefore use of this code can be considered to have been appropriate. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code G0453-XU rendered on May 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on March 9, 2023. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for radiological services provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on June 19, 2023. 
 
You asked the Plan to pay for medication assisted treatment. You say that you are requesting reconsideration 
for 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 medication assisted 
treatment provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215), ambulatory continuous glucose 
monitoring of interstitial tissue fluid (95351), and laboratory test (83036) provided on May 23, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that this claim should be reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99215), ambulatory continuous 
glucose monitoring of interstitial tissue fluid (95351), and laboratory test (83036) provided on May 23, 2023, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 15, 2023, 
to March 16, 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 15, 2023. The NOA was not received by the Plan until August 21, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 15, 2023, to March 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on April 26, 2023, to April 28, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you have 
already had to pay for MRIs and CT scans, and feel its unfair that you need to pay this now. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $380 
copayment for inpatient hospital services.  
You have been asked to pay a $380 copayment for an in-network acute inpatient stay. This item/service falls 
within the inpatient 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. You have been asked to pay a total of $760 for the inpatient hospital stay ($380 
copayment x 2 days = $760). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided on 
April 26, 2023, to April 28, 2023.