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

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
February 26, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this 
determination and coverage of the Tempus Liquid CGP Panel test at the in-network benefit level. The Plan 
denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion 
in vitro diagnostic or an FDA-approved or cleared indication for use in this enrollees cancer. 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 pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
February 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 8, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 2, 2023, billed 
with evaluation and management (EM) code 99203-25. 
 
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 follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation does not support the billed code. Our physician reviewer found that in this 
case the procedure and modifier 25 cannot be verified, as evaluation and management service provided is 
related. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 2, 2023, billed with evaluation and 
management (EM) code 99203-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87529 billed for date of service January 24, 
2023. 
 
You asked the Plan to pay for procedure code 87529. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported for separate payment in 
this case. 
 
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 87529 is a column II code to column I code 87801; however, 87529 
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 procedure code 87529. Our reviewer says that this code is 
not supported for separate reporting. Our reviewer found the laboratory includes documentation of Herpes 
simplex virus; however, the laboratory report does not include documentation to support that this procedure 
was distinct from infectious agent detection, multiple organisms, amplified probe technique. Therefore, this 
procedure and modifier denied correctly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87529 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87529 billed for date of service January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 28, 
2022 to July 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. 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 28, 2022 to July 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the inpatient hospital stay provided by an 
in-network provider from January 6, 2023, to January 9, 2023. 
 
You asked the Plan to waive the cost sharing for the inpatient hospital stay. You say that you do not feel that 
you should have to pay. 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 5% 
coinsurance per admission for in-network inpatient care. 
 
 
 You have been asked to pay a $423.69 coinsurance for the inpatient hospital stay ($8473.37 allowed amount x 
.05 = $423.69 rounded up). This item/service falls within the inpatient hospital 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 cost sharing for the inpatient hospital stay provided by an in-network 
provider from January 6, 2023, to January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
March 7, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says the requested test is not reasonable and necessary because Tempus xF has not had 
FDA approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) 
provided March 7, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
January 19, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
January 19, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management 
(90867 x1), therapeutic repetitive TMS treatment; subsequent delivery and management, per session (90868 
x34), and therapeutic repetitive TMS treatment; subsequent motor threshold re-determination with delivery and 
management (90869 x1). 
 
You asked the Plan to pre-approve therapeutic repetitive TMS treatment; initial, including cortical mapping, 
motor threshold determination, delivery and management, therapeutic repetitive TMS treatment; subsequent 
delivery and management, and therapeutic repetitive TMS treatment; subsequent motor threshold re-
determination with delivery and management. 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 TMS 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 therapeutic repetitive TMS treatment; 
initial, including cortical mapping, motor threshold determination, delivery and management, therapeutic 
repetitive TMS treatment; subsequent delivery and management, and therapeutic repetitive TMS treatment; 
subsequent motor threshold re-determination with delivery and management. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the information provided, you do 
not meet the clinical criteria for continued use of TMS therapy as she has had undergone a complete trial of 
TMS. Continued treatment is considered 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 therapeutic repetitive TMS treatment; initial, including cortical mapping, motor 
threshold determination, delivery and management, therapeutic repetitive TMS treatment; subsequent delivery 
and management, and therapeutic repetitive TMS treatment; subsequent motor threshold re-determination with 
delivery and management have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, 
motor threshold determination, delivery and management (90867 x1), therapeutic repetitive TMS treatment; 
subsequent delivery and management, per session (90868 x34), and therapeutic repetitive TMS treatment; 
subsequent motor threshold re-determination with delivery and management (90869 x1).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve 60 additional trips. You say that the enrollee requires additional non-
emergency transportation to attend medical appointments. You also say that providing additional transportation 
would be cost-effective as it would potentially prevent costly hospital admissions. The Plan denied your 
request. The Plan says additional transportation beyond the benefit is not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0433, A0425) provided on January 14, 
2023. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT codes A0433, & A0425 are not supported in the medical record. Specifically, Diagnosis 
Code I46.8 is not a valid primary diagnosis. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0433, A0425) provided on January 14, 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 your doctor recommended rehab in order to regain 
strength to live independently. The Plan denied your request. The Plan says the IRF services you are requesting 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits on October 25, 2022, to 
February 22, 2023.  
 
You asked the Plan to waive the copayments for office visits. You say that you want to appeal the amount 
being charged. 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 $40 
copayment for $40 copay for Medicarecovered physician specialist services (including surgery second 
opinion, telehealth services, home infusion professional services, and urgently needed services). You must pay 
a $35 copay for Medicarecovered physician specialist services (including surgery second opinion, telehealth 
services, home infusion professional services, and urgently needed services). Covered services include 
consultation, diagnosis, and treatment by a specialist. $40 + $35 = $75. Therefore, results in the total cost 
sharing amount of $75. 
 
You have been asked to pay a $40 copayment and a $35 copayment for office visits. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 copayments for office visits on October 25, 2022, to February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 21, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. 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 
January 21, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321 and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on February 14, 
2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you should not be liable for the 
office visit. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to doctor and other health care 
provider services. Your contract with the Plan clearly says that you must pay 10% coinsurance for practitioner 
services. 
 
You have been asked to pay $90.49 towards your deductible for the office visit, The item or service you asked 
the Plan to waive the cost share for falls within the doctor and other health care provider services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to doctor and other health care provider services. This cost sharing is a contractual 
obligation that had not been met at the time an office visit was received on February 14, 2023.  
 
You have also been asked to pay $10.06, which is 10% coinsurance of the allowed amount for the office visit. 
You have been asked to pay aa total of $100.55 ($90.49 deductible + $10.06 coinsurance = $100.55). This 
item/service falls within the doctor and other health care provider 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 an office visit provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not medical need to control these power options 
through a joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicate the enrollee has adequate upper body 
strength to manage standard power drives. Therefore, the reviewer found that the need for upgraded electronics 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cardiac rehabilitation visit provided 
on January 04, 2023, to January 30, 2023. 
 
You asked the Plan to waive the copayment for each cardiac rehabilitation visit. You say that you were never 
told you would have financial responsibility. 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 $10 
copayment for cardiac rehabilitation services. 
 
You have been asked to pay a $10 copayment for each cardiac rehabilitation visit. This item/service falls within 
the cardiac rehabilitation 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. The total you owe is $70 ($10 copayment x 7 visits = $70). Therefore, we 
decided that the Plan does not have to waive the copayment for each cardiac rehabilitation visit provided on 
January 04, 2023, to January 30, 2023.