Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the below knee, flexible protective outer surface 
covering system (L5962).  
 
You asked the Plan to pre-approve the outer surface covering system. You say that you kindly ask for 
reconsideration for the new prosthesis to be covered. The Plan denied your request. The Plan says the extra 
prosthetic cover exceeds the enrollee's needs. A standard cover has already been approved. 
 
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 outer surface covering system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support that the enrollee has needs for 
protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by already approved L5704. 
 
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 outer surface covering system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the below knee, flexible protective outer surface covering system 
(L5962).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on June 27, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT 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 definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
documentation does not support that testing for 22 or more drug classes was 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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on June 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve capecitabine. 
 
You asked the Plan to pre-approve the medication. You say that this medication is needed for the enrollee's 
melanoma cancer. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 pre-approve capecitabine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service August 31, 
2022.  
 
You asked the Plan to pay for procedure code 95861. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed number of units is not 
supported by the records as both provided and medically necessary.  
 
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 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 95861. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found that the enrollee underwent 
revision spinal surgery for which intraoperative neuromonitoring was provided. The documentation indicates 
that electromyography (EMG) monitoring of both lower extremities was conducted. There is no evidence that 
two separate EMG monitoring episodes occurred.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95861 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 95861 billed for date of service August 31, 2022.
Appeal type: Lab
Decision: Favorable

. 
 We decided that the Plan has to pay for the genetic testing provided on May 31, 2023.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was billed with a missing or invalid DEX Z-code.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan argues that the claim was billed with a missing or invalid DEX Z-code. However, the claim was billed with DEX Z-code ZB42N. The Plan has not provided documentation showing this code is incorrect for the billed testing. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the genetic testing provided on May 31, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this code was authorized. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Signatera testing. 
 
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 minimal residual disease testing is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
moderately differentiated adenocarcinoma of the colon that has metastasized to the liver. On August 21, 2023 it 
is documented that the enrollee did not want to continue with chemotherapy. There is no documentation in the 
clinical records that the enrollee is being treated with immune checkpoint inhibitor (ICI) therapy. The criteria 
for coverage are not met and the testing is therefore 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 Signatera testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94060 billed for date of service July 6, 
2023. 
 You asked the Plan to pay for procedure code(s) 94060. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 94060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 94060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 94060 billed for date of service July 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided May 17, 2022 to June 15, 
2022. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
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 March 18, 2022. The NOA was not received by the Plan until September 
22, 2022. 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 home health services provided 
May 17, 2022 to June 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on  
June 22, 2023. You also asked the Plan pay for the self-administered drug provided on June 22, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you should not be 
responsible to pay this 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for emergency room services. This item/service falls within the 
emergency care 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 copayment for emergency room services 
provided on June 22, 2023. You have also been asked to pay $0.50 for the self-administered drug provided on 
June 22, 2023. This drug does not meet criteria for coverage under Medicare Part B. The total you owe is 
$110.50 ($110.00 + $0.50 = $110.50). 
 
Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you require SNF care due to weakness and inability 
to care for your leg infection. The Plan denied your request. The Plan says you do not meet Medicare 
guidelines for SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0452-26-59) provided May 25, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 G0452 is a column II code to column I code 81450; however, G0452 
was billed with a modifier.  
 
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 drug testing. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The provider reported laboratory reported procedure code 
with appended modifier 59 distinct procedural service to bypass NCCI Edit with CPT 81450 Targeted Genomic 
Sequence Analysis Panel. The medical record submitted does not include documentation to support a distinct 
procedural service. Healthcare Common Procedure Coding System (HCPCS) code G0452 (molecular 
pathology procedure; physician interpretation and report) is used to report a medically necessary interpretation 
and written report of a molecular pathology test, above and beyond the report of laboratory results. The review 
of the test results is considered to be part of the medical decision-making key component and is not separately 
billable.   
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing (G0452-26-59) provided May 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 87631) performed on June 21, 
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 the records do not support the services 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 87631 is "Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, 
influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 3-5 targets." 
 
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 the documentation does support that 
CPT 87631, with 3-5 targets, was performed. The enrollee had respiratory pathogen profiling performed. 
 
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 
laboratory services (procedure code 87631) performed on June 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2023, billed with 
code 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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. 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 
April 11, 2023, billed with code 81345.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88271 and 85060 billed for date of service 
May 1, 2023. 
 
You asked the Plan to pay for procedure codes 88271 and 85060. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 88271 is bundled into payment for code 
81261. Code 85060 was billed incorrectly. 
 
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 88271 
is a column II code to column I code 81261. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 85060 was billed on the claim. This code has a Professional Component (PC)/Technical 
Component (TC) Indicator "8". This indicator identifies the professional component of clinical laboratory 
codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital 
inpatient. No TC billing is recognized because payment for the underlying clinical laboratory test is made to 
the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital 
outpatients or non-hospital patients. 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 codes 88271 and 85060 billed for date 
of service May 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that the use of Entyvio will help with your condition.  The 
Plan denied your request. The Plan says you do not meet the coverage criteria for Entyvio. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 for Entyvio. Our reviewer says that the 
use of Entyvio has not shown any clinical improvement to your condition. Our physician reviewer found the 
use of Entyvio for ulcerative colitis beyond 14 weeks with no therapeutic benefit does not meet the Medicare 
criteria for safe and effective and is otherwise unreasonable and unnecessary 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 for Entyvio have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the continued use of Entyvio.