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

 
We decided that the Plan does not have to pay for the laboratory services provided on August 01, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on August 01, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on July 20, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that code G0482 is bundled into payment for 
code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has withdrawn the rule stating that code 
G0482 is bundled into code 80307. Code G0482 is now separately payable from code 80307 in accordance 
with the bulletin that CMS published on its website along with the 2023 Q4 NCCI files. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0482 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0482 provided on July 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potential study and 
neurophysiology monitoring provided on June 30, 2023. 
 
You asked the Plan to pay for short-latency somatosensory evoked potential study and neurophysiology 
monitoring. You say that the short-latency somatosensory evoked potential study and neurophysiology 
monitoring was medically necessary. The Plan denied your request. The Plan says the short-latency 
somatosensory evoked potential study and neurophysiology monitoring was not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that short-latency somatosensory evoked potential study 
and neurophysiology monitoring is covered when the criteria listed in the Medicare rules section of this 
decision 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 short-latency somatosensory evoked 
potential study and neurophysiology monitoring. Our reviewer says that the requested short-latency 
somatosensory evoked potential study and neurophysiology monitoring is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the provided medical records document a 
percutaneous spinal cord stimulator trial was performed on June 30, 2023 with use of a short-latency 
somatosensory evoked potential study and intraoperative neurophysiology monitoring. The Medicare Local 
Coverage Determination (LCD: L34624) states that an intraoperative short-latency somatosensory evoked 
potential study is indicated for spinal surgeries in which there is risk of additional nerve or spinal cord injury. 
The provided records do not include adequate detail to show the procedure on June 30, 2023 met the LCD 
definition of a spinal surgery in which there is risk of additional nerve or spinal cord injury. The provided 
records are inadequate to demonstrate necessity of the intraoperative neurophysiology monitoring as 
summarized in the current peer-reviewed medical literature. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of short-latency somatosensory evoked potential study and neurophysiology 
monitoring have not been met. Therefore, we decided that the Plan does not have to pay for short-latency 
somatosensory evoked potential study and neurophysiology monitoring on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 4, 2023, billed with 
procedure code 99204. 
 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 documentation does not support the billed code. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the provided documentation 
indicates that the enrollee has received face-to-face services from another provider in the same group practice 
within the past 3 years. 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 August 4, 2023, billed with procedure code 99204.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
additional items and accessories (codes K0108, E2361, E1028, E1007, E2300, E2620, E0955, E1012, E0995, 
E0953, E2377, E2313, E2311, E2608, E1028, E1028, K0108, K0108, and K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that it was determined that 
a custom power wheelchair with a power tilt, power recline, and elevating leg rests would be the most effective 
chair that will help the enrollee with completion of activities of daily living in the home. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options included with a 
K0861 Group 3 power wheelchair. 
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee requires family assistance.to stand but the enrollee is able 
to stand and walk. Per L33789, as the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional 
items and accessories (codes K0108, E2361, E1028, E1007, E2300, E2620, E0955, E1012, E0995, E0953, 
E2377, E2313, E2311, E2608, E1028, E1028, K0108, K0108, and K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard esophageal DNA (deoxyribonucleic acid) test 
(0114U) provided on July 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that as the only provider of the test, you should 
be considered in-network. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 requested 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. Also, per the DEX Diagnostic Exchange registry EsoGuard is not covered. 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 EsoGuard esophageal DNA (deoxyribonucleic acid) test (0114U) provided on July 19, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need this device to get around inside and 
outside. You also say that you would not have applied if you could walk. The Plan denied your request. The 
Plan says this device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle may be covered when 
the beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Specifically, the record does not show that a home assessment 
has been performed. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental sedation (D9222, D9223). 
 
You asked the Plan to pre-approve dental sedation. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental sedation (D9222, D9223).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS device is 
medically necessary. The Plan denied your request. The Plan says medical studies have not proven this service 
is helpful for the treatment of the enrollee's health problem.  
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
July 25, 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 a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 urine polymerase chain reaction (PCR) 
panel rendered on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the indication 
for hyperbaric oxygen under pressure is for hearing loss. This is not indicated in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy (99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B drug injections and office 
visits provided from September 27, 2022, to December 22, 2022. 
 You asked the Plan to waive the cost share for Medicare Part B drug injections and specialist office visits. You 
say that you disagree with the cost share applied. 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 Medicare Part B prescription drugs.  
 
You have been asked to pay $67.62 for Medicare Part B drug injections and office visits.  
 
Date of Service Service Rendered Amount 
Allowed 
Amount per 
Contract 
Cost Share Applied 
September 27, 2022 Injection (J3301) $20.64 20% coinsurance $4.13 coinsurance 
September 27, 2022 Specialist visit 
(99213) 
$90.96 $20 copayment $20 copayment 
(Paid on September 30, 2022) 
November 2, 2022 Specialist visit 
(99213) 
$90.96 $20 copayment $20 copayment 
December 22, 2022 Specialist visit 
(99213) 
$90.96 $20 copayment $20 copayment 
December 22, 2022 Injection (J3301) $17.44 20% coinsurance $3.49 coinsurance 
Total    $67.62 
 
The Medicare Part B injections falls within the Medicare Part B prescription drugs benefit category. The 
specialist visits fall within the physician/practitioner 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 share for Medicare Part B drug injections and office visits provided from September 27, 2022, 
to December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 2, 2023, billed with 
procedure code 99308. 
 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 the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code H10.213, 
described as acute toxic conjunctivitis, bilateral. This code is not an appropriate primary diagnosis as the code 
has a code first note indicating to code the underlying condition first. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on May 2, 2023, billed with procedure code 99308.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240). 
 
You asked the Plan to pre-approve the genetic testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has a non-coverage policy for genetic 
testing for thrombophilia testing for the Factor V Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) 
variant in the F2 gene, and the MTHFR gene which encodes the 5, 10 methylenetetrahydrofolate reductase 
enzyme. Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including 
cardiovascular risk assessment, are non-covered except for pregnant patients. 
 
We looked at the file and Medicare rules. This test is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the ostomy supplies provided on June 20, 
2023. 
 
You asked the Plan to reduce the coinsurance for the ostomy supplies. You say that you disagree with the cost 
share. 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 ostomy 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. Therefore, we decided that the Plan does not have to reduce the 
coinsurance for the ostomy supplies provided on June 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on August 17, 2023, billed with 
procedure code 81479. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the test performed is not covered by Medicare. 
 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 shows that the test performed is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of the testing services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
provided on August 17, 2023, billed with procedure code 81479.