Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 dates of service June 18, 2023, to July 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that that this request does not meet their guideline for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that it is safe to say that IMRT is not experimental, but rather a useful tool available to radiation 
oncologists to potentially reduce toxicity and improve the lung and skin dose distributions. In 2022, American 
Society for Radiation Oncologys (ASTRO) updated their Choosing Wisely list to remove the following: Do 
not routinely use intensity modulated radiotherapy (IMRT) to deliver whole breast radiotherapy as part of 
breast conservation therapy. In light of the dosimetric improvement with IMRT in this enrollee, as well as 
ASTROs most recent update of its Choosing Wisely list, IMRT for this enrollee would be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT).  
 
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 FoundationOne Liquid CDx (F1LCDx) testing (0239U) 
provided on July 25, 2023. 
 
You asked the Plan to pay for F1LCDx testing. You say that this test was medically necessary and is supported 
in the medical records. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of this service. 
 
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 pay for F1LCDx testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a prostate biopsy in March of 2023, and there is no documentation to show 
why this solid tissue sample cannot be used for next generation sequencing. The National Comprehensive 
Cancer Network (NCCN) guidelines recommends reserving plasma/liquid testing for when tissue cannot be 
used. Therefore, this test was not 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 F1LCDx testing have not been met. Therefore, we decided that the Plan does 
not have to pay for FoundationOne Liquid CDx (F1LCDx) testing (0239U) provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on July 3, 2023.

You asked the Plan to pay for the COVID-19 test. You say that you want to be reimbursed payment. The Plan denied your request. The Plan says the item is not covered benefits.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on July 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Womens Health Plus Panel provided on April 4, 2023, 
and billed with codes 81513, 81514, 87481, 87491, 87511, 87529, 87591, 87625, 87640, 87653, 87661, and 
87798. 
 
You asked the Plan to pay for the Womens Health Plus Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Womens Health Plus Panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the Womens Health Plus Panel provided on April 4, 2023, and billed with codes 81513, 81514, 87481, 87491, 87511, 87529, 87591, 87625, 
87640, 87653, 87661, and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D5120) on July 21, 2023. 
 
You asked the Plan to pay for the dental service (D5120). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 21, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental service (D5120) on July 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 22, 2023, billed with 
codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. 
 
The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single 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 May 22, 2023, billed with codes 81314 and 81345.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-periapical x-ray each additional radiographic 
image (D0230 x2) provided on April 27, 2023. 
 
You asked the Plan to pay for the dental x-rays. You say that you were advised to pay with your debit card and 
request a reimbursement. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2023 when you 
received one intraoral-periapical x-ray (D0220). Therefore, we decided that the Plan does not have to pay for 
an intraoral-periapical x-ray each additional radiographic image (D0230 x2) provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents (D4381) provided 
on June 1, 2023. 
 
You asked the Plan to pay for D4381. You say that you were told that this would be covered complete. The 
Plan denied your request. The Plan says the denied dental service is not a covered benefit. 
 
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 pay for localized 
delivery of antimicrobial agents (D4381) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 14, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee has a much higher potential for 
a good outcome if admitted to an LTACH, rather than waiting until he can be discharged to a skilled nursing 
facility. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to move to 
an LTACH for acute level care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time; the enrollee is not appropriate for transfer to an LTACH. The enrollee 
has a number of ongoing acute care needs, including concern for intermittent need for continuous renal replacement therapy. The enrollee is receiving appropriate inpatient care at the current setting and does not 
require an LTACH transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 12, 2023, billed with 
procedure codes 70496 and Q9967. 
 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 claim was billed with an inappropriate 
principal diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that family history code(s) should not be assigned as 
a principal diagnosis. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The claim denied correctly as it was reported 
with an inappropriate principal diagnosis. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on June 12, 2023, billed with procedure codes 70496 and Q9967.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vasectomy. 
 
You asked the Plan to pre-approve a vasectomy. You say that the requested vasectomy is medically necessary. 
The Plan denied your request. The Plan says a vasectomy is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that elective hysterectomy, tubal ligation, and 
vasectomy, if the primary indication for these procedures is sterilization, is non-covered. 
 
We looked at the file and Medicare rules. The file shows that you are requesting elective sterilization. Medicare 
says a vasectomy, if the primary indication for these procedures is sterilization, is non-covered. Based on this 
information, we decided that Medicare rules for coverage of a vasectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a vasectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis billed for date of service April 25, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the records do not support the services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthosis billed 
for date of service April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to crown (D6058) for tooth #4 provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary. 
The Plan denied your request. The Plan says the denial of payment for the abutment supported to crown is 
correct because the x-rays did not show the prosthetic in place. Also, the custom fabricated abutment is not 
covered by the Plan. 
 
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. The Plan covers the abutment 
supported to crown when the services are medically necessary and reasonable.  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 dental services. Our reviewer says that 
the abutment supported to crown coverage criteria was not met. Our physician reviewer found that the service 
would be reasonable and necessary to restore an existing implant. The implant body is clearly seen in the 
provided x-ray, which was taken prior to placement of the abutment or crown. There is a requested custom 
abutment and an abutment supported crown. Both would be considered necessary to restore the implant, though 
it appears the custom abutment is not a covered service. 
 
The Plan requires a post treatment x-ray confirming placement of the final crown on the abutment. The crown 
would be a covered service, though the custom abutment would not be a covered service. The crown would be 
a covered service after the placement of the crown on an abutment were confirmed with an x-ray. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the abutment supported to crown have not been met. The custom fabricated 
abutment is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a custom fabricated abutment (D6057) and an abutment supported to crown (D6058) for tooth #4 
provided on November 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on July 12, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like the clam to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service July 24, 
2023.  
 
You asked the Plan to pay for procedure code 88360. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 88360 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87150, 87481, 87641, 87653, 87798 
and 87801) billed for date of service July 31, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87150, 87481, 87641, 87653, 87798 and 87801) billed for 
date of service July 31, 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 enrollee requires full assistance for functional 
mobility, moderate for feeding and grooming, moderate assistance for upper activities of daily living, and full 
assistance for lower activities of daily living. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
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.