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

 
We decided that the Plan does not have to pre-approve Oncogenomic Heme V2.0 panel (81455). 
 
You asked the Plan to pre-approve Oncogenomic Heme V2.0 panel. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Oncogenomic Heme V2.0 panel. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found this specific genomic 
panel is not listed as an approved test in the MoIDX Program at the time of this request which suggests 
insufficient high-quality evidence to support its use in this clinical situation. Therefore, this request for the 
Oncogenomic Heme V2.0 panel will be considered not medically necessary 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 Oncogenomic Heme V2.0 panel have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Oncogenomic Heme V2.0 panel (81455).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 reader. You say that the enrollee has leg weakness and 
is high risk for falls. You also say that the enrollee was recently started on insulin. The Plan denied your 
request. The Plan says conditions for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of the 
FreeStyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve 
FreeStyle Libre 2 reader.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 June 1, 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 the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services provided on January 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for procedure code 97010. You say that this service has been pain on previous 
claims. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service March 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous lysis of epidural adhesions using 
solution injection. 
 
You asked the Plan to pre-approve the percutaneous lysis of epidural adhesions using solution injection. You 
say that the service is medically necessary. The Plan denied your request. The Plan says the injection or 
mechanical removal of spinal canal scar tissue is not medically necessary. The Plan says there are not enough 
scientific studies that show the procedure is safe and effective. 
 
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 percutaneous lysis of epidural 
adhesions using solution injection. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for radiculopathy of the lumbosacral region. The documentation shows that an epidural steroid injection resolved 
the enrollee's radicular symptoms. There are no objective exam findings noted on the recent examinations. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested percutaneous lysis of epidural 
adhesions using solution injection is not medically reasonable or 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 percutaneous lysis of epidural adhesions using solution injection have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous lysis of epidural 
adhesions using solution injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 19, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that you were not provided correct insurance 
information. The Plan denied your request. The Plan says you did not timely file your claim. The Plan follows 
Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no 
later than one calendar year after the date of service. The record shows that a claim for the lab services was not 
filed until April 10, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for lab services provided on 
January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of an abscess-extraoral soft tissue 
(D7521) provided on October 4, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incision and 
drainage of an abscess-extraoral soft tissue (D7521) provided on October 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says  the Intracept procedure is 
not medically necessary because the procedure is investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. This means that the cause of pain is not clear, and criteria has 
not been met.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee cannot see and is unable to 
put the test strips in the machine and apply a drop of blood. You also say that the enrollee is unable to do it on 
their own. The Plan denied your request. The Plan says based on a review of the information received, the 
enrollee is not on insulin or has a documented history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia, and had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose 
monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemical peel, facial (15789) and destruction 
cutaneous vascular proliferative lesions (17107). 
 
You asked the Plan to pre-approve a facial chemical peel and destruction of skin lesions. You say that you have 
submitted medical records to support the reconsideration of the denied services. The Plan denied your request. 
The Plan says the chemical peel treatment for actinic keratosis and laser treatment of hemangioma are 
considered not medically necessary as there is no functional deficit/impairment and they are being done for 
cosmetic purpose. 
 
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 a facial chemical peel and destruction 
of skin lesions. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested chemical peel treatment for actinic 
keratosis and laser treatment of hemangioma are considered not medically necessary and would serve only a 
cosmetic purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facial chemical peel and destruction of skin lesions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a chemical peel, facial (15789) and 
destruction cutaneous vascular proliferative lesions (17107).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 system. 
 
You asked the Plan to pre-approve the Dexcom G7 system. You say that the Freestyle 2 you have is not 
working properly and the Dexcom 7 is a better system. You also say that you cannot prick your fingers due to 
thin skin, so this is a device that is needed to replace that. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G7 system. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service April 4, 2023, and 
April 5, 2023. 
 
You asked the Plan to pay for code 99233. You say that the medical record includes a dictation and 
transcription date and time, so that is sufficient for payment. The Plan denied your request. The Plan says this 
code is not supported by the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, although you provided 
medical records, the records are not dated. A dictation or transcription date does not substantiate when the 
service was physically performed, only when the note was generated. As a result, we cannot determine if the dates of service billed accurately correspond to when the services were rendered. Based on this information, we 
decided that Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99233 billed for dates of service April 4, 2023, and April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (1137F, 97810, 97811, 97814, 
99080) provided on March 2, 2023, by an OON provider.  
 
You asked the Plan to pay for acupuncture services (1137F, 97810, 97811, 97814, 99080). You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says this service was not 
authorized. 
  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. 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 acupuncture services (1137F, 97810, 97811, 
97814, 99080) provided on March 2, 2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 17, 2022, to January 18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you waited all 
night for medical services, but nothing was done so you decided to go home. 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 $90 
copayment for Emergency Care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. 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 an emergency room 
(ER) visit provided on January 17, 2022, to January 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 01, 2023, to April 02, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you should not 
have a copayment when you were admitted for two nights. 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 an emergency room (ER) visit. 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 an 
emergency room (ER) visit provided on April 01, 2023, to April 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service January 22, 2023, to 
January 31, 2023. 
 
You asked the Plan to pay for code 99233. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 99233 is not supported by the medical record. This 
code requires a high level of medical decision making or 50 minutes to be documented in the note. The medical 
records indicate that this service should have been coded as 99232, because there was moderate medical 
decision making. 
 
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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99233. Our reviewer says that code 99233 is not 
supported by a medical record. Our reviewer found the patient is a 79-year-old woman who was admitted to the 
psychiatric floor with major depression and had cough and chest congestion. 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 code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service January 22, 2023, to January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83880-GZ billed for dates of service April 14, 2023, to 
April 15, 2023. 
 
You asked the Plan to pay for code 83880-GZ. You say that you provided medical records to support payment. 
The Plan denied your request. The Plan says this service is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all claim lines submitted with the GZ modifier 
are automatically denied.  The code in question was billed with the GZ modifier, so no payment can be made 
for this code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83880-GZ have not been met. Therefore, we decided that the Plan does not have to pay for 
code 83880-GZ billed for dates of service April 14, 2023, to April 15, 2023.