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

 
We decided that the Plan does not have to pay for the services (0242U) provided on February 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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. 
 
In this case, the CPT Code Manual definition of code 0242U is "Targeted genomic sequence analysis panel, 
solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, 
gene copy number amplifications, and gene rearrangements". 
 
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 code 0242U is 
not supported by the records provided. Our reviewer found that the medical records provided does not include sufficient documentation to validate that a "targeted genomic sequence analysis panel, solid organ neoplasm, 
cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number 
amplifications, and gene rearrangements" was performed February 23, 2023. Therefore, this service cannot be 
verified. 
 
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 (0242U) provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
March 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that you are obligated to process the specimens you 
receive. 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. 
 
In this case, the CPT Code Manual definition of code 83520 immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that 5 units of CPT code 83520 and 1 unit of code 87798 is not supported in the medical record. The 
records show that multiple immunoassays and stool tests were ordered. Neither the claim nor the medical 
records identifies the organisms associated with each code. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 83520 and 87798 billed for date of service March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis C antibody screening (G0472) provided on 
February 7, 2023. 
 
You asked the Plan to pay for the Hepatitis C antibody screening. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says no medical records were submitted to support the 
medical necessity of this service. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Hepatitis C antibody screening have been met. In this case no medical records were provided for review. Without this information we are 
unable to verify whether the requested testing was medically reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for the Hepatitis C antibody screening (G0472) provided on February 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, and 96521 for date of service April 6, 
2023. 
 
You asked the Plan to pay for codes 96365, 96366, and 96521. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the evidence is adequate to conclude that 
outpatient intravenous (IV) insulin therapy (OIVIT) does not improve health outcomes in Medicare 
beneficiaries. 
 
 We looked at the file and Medicare rules. Review of the file shows that the services at issue are for OIVIT. 
These services are not covered. Based on this information, we decided that Medicare rules for coverage of 
codes 96365, 96366, and 96521 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 96365, 96366, and 96521 for date of service April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 28, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on February 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on June 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function".  
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 code 99285 is 
not supported by the records provided. Our reviewer found that the records do not support medical decision-
making of high complexity. 
 
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 (99285) provided on June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6216 and A6219 billed for date of service 
March 23, 2023. 
 
You asked the Plan to pay for procedure codes A6216 and A6219. You say that you received a denial for these 
items, but this claim should be paid. The Plan denied your request. The Plan says procedure code A6216 and 
A6219 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 codes A6216 and A6219 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A6216 and A6219 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A6216 and A6219 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A6216 and A6219 billed for date of service 
March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the referring physician does not agree with a lower 
level of care. The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99205) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
office visits (99204, 99205) 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 procedure code 96040-95 billed for date of service May 16, 
2023. 
 
You asked the Plan to pay for procedure code 96040-95. This was the code billed for the genetic testing you 
had. You say that it was critical that you had this genetic testing done and it was not trivial. The Plan denied 
your request. The Plan says procedure code 96040-95 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 96040-95 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 96040-95 is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 96040-95 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96040-95 billed for date of service May 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer. There 
is insufficient literature to support the safety and efficacy of HIFU. The services are not reasonable or 
medically necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high-intensity focused ultrasound (HIFU).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve travel fees from outside the U.S. provided from 
February 19, 2023, to February 21, 2023. 
 
You asked the Plan to pre-approve travel fees from outside the U.S. You say that these travel costs were at the 
direction of the doctor whose care you were under. The Plan denied your request. The Plan says the worldwide 
emergency services benefit does not cover commercial travel, hotels, resort fees, meals, spas, massages, 
acupuncture, taxis or gratuities. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover services outside of the 
United States. Medicare also does not cover transport in a vehicle that is not an ambulance. However, the Plan 
offers coverage for emergency transportation outside the U.S. For that reason, the Plans coverage rules apply 
in this case. 
 
We looked at the file, Medicare rules, and the Plan rules. The Plan rules say that they over coverage for 
emergency transportation outside the U.S. However, emergency transportation would be ambulance services or 
the equivalent, not commercial travel. While you may have needed to travel due to your medical condition, the 
travel fees are not listed as covered. The record shows that the travel fees incurred for these dates of services 
are commercial. Based on this information, we decided that Medicare rules for coverage of travel fees have not 
been met. Therefore, we decided that the Plan does not have to pre-approve travel fees from outside the U.S. 
provided from February 19, 2023, to February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain 
(CLBP) will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Transcutaneous Electrical Nerve Stimulator (TENS) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were the only provider available to provide 
these services. 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 office visit provided 
on May 10, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has arthropathic psoriasis. 
She has not tried and failed the Plan's required drugs; Remicade, Infliximab or Inflectra, or Simponi Aria, and 
Stelara. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Avsola is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Avsola.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for an ER visit. We decided that the Plan does not have to 
waive the cost for self-administered drugs.  
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs provided from May 23, 2023, 
to May 24, 2023.. You say that you disagree with the cost share applied. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the copayment for an ER visit.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan charged you a $95 copayment for an ER visit. 
However, your contract with the Plan states that you will pay $0 copayment for emergency care services. 
Therefore, we decided that the Plan has to waive the copayment for an ER visit.  
 
We also decided that the Plan does not have to waive the cost for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to waive the cost for self-administered 
drugs. 
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights. 
 
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 pay for the wound care supplies provided on July 27, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies do not require 
authorization. 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 wound care supplies 
provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.