Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64445) provided on January 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 64445 is 
not supported by the records provided. Our reviewer found that the medical records state that a post-operative 
nerve block was performed, however in accordance with medical coding guidelines, the post-operative pain 
injection would be considered bundled in the procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (64445) provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on January 2, 2023, to January 11, 2023. 
 
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 that a hemoglobin or hematocrit reading was not 
reported on the billed claim, and the required erythropoiesis stimulating agent (ESA) modifier was not given. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan cited two potential billing rules for the denial, but both billing criteria are met by the claim as the 
J0882 code was billed with modifier -JB, and value code 49 was reported as required. As such, the Plans denial 
of payment for these services is not substantiated. Therefore, we decided that the Plan has to pay for 
practitioner services provided on January 2, 2023, to January 11, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for F2 (prothrombin, coagulation factor II) genetic testing 
(81240) provided on August 26, 2022. 
 
You asked the Plan to pay for F2 gene testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that F2 genetic tests are not considered clinically efficacious and 
therefore are not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 gene testing have not been met. Therefore, we decided that the Plan does not have to pay for F2 
(prothrombin, coagulation factor II) genetic testing (81240) provided on August 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 4, 2023, to 
March 5, 2023. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2023. The NOA was not received by the Plan until April 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 4, 2023, to March 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
April 10, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of the 
laboratory services. The Plan denied your request. The Plan says the requested genetic test, GeneSight gene 
panel, does not meet the requirements for approval.  
 
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 the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has a diagnosis is borderline personality 
disorder and depression. There is no provider generated medical records for review. Additional information 
was requested but not received. The review has determined that the requested services do not meet the 
coverage criteria. The items/services at issue in this case are 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure (81479) provided April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services identified with procedure codes 
87481, 87491, 87563, 87640, and 87798 for date of service July 12, 2022.  
You asked the Plan to pay for procedure codes 87481, 87491, 87563, 87640, and 87798. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says no physician order/lab requisition 
was provided. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that a physician order/lab requisition or medical records stating exactly what tests 
were to be performed was not provided. The submitted laboratory requisition form indicates that a "NAME OF 
PANEL" panel was requested. The submitted documentation does not itemize what tests are included in this 
panel; therefore, the billed codes cannot be verified. This means the documentation does not support that the 
testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services identified with procedure codes 87481, 87491, 87563, 87640, and 87798 for date of service July 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99219) provided on October 18, 2022 to 
October 20, 2022. 
 
You asked the Plan to pay for the observation care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not supported by the records submitted. 
 
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 99219 is initial observation for the evaluation and 
management of a patient, requiring a comprehensive history; a comprehensive examination; and medical 
decision making of moderate complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the observation care. Our reviewer says that the billed code is 
not supported by the records. Our reviewer found the medical records submitted did not support a 
comprehensive examination. 
 
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 observation care have not been met. Therefore, we decided that the Plan 
does not have to pay for observation care (99219) provided on October 18, 2022 to October 20, 2022.
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 
March 1, 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 urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR 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 March 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no evidence of a trial of conservative measures, including physical 
therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the enrollee was diagnosed with possible 
sciatica or gluteus tendonitis. The x-ray showed evidence of mild osteoarthritis of the hips but no acute 
abnormality. An MRI lumbar spine was requested. The provided documentation did not reveal evidence of a 
red-flag diagnosis based on examination and there was no report of recent exhaustion of conservative 
treatments such as exercises prior to the consideration of advanced imaging. Therefore, the MRI 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spine.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillectomy, without orbital exenteration (CPT 31225) 
at the outpatient level of care. 
 
You asked the Plan to pre-approve maxillectomy, without orbital exenteration at the outpatient level of care. 
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 maxillectomy, without orbital 
exenteration at the outpatient level of care. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical 
records provided there is no documentation that the maxillectomy, without orbital exenteration at the outpatient level of care at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
enrollee. Maxillectomy, without orbital exenteration is on Medicare's 2023 Inpatient-Only Procedure Code list; 
coverage for the procedure at the outpatient level does not meet Medicare criteria for safety, efficacy and 
necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of maxillectomy, without orbital exenteration at the outpatient level of care have 
not been met. Therefore, we decided that the Plan does not have to pre-approve maxillectomy, without orbital 
exenteration (CPT 31225) at the outpatient level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement, arterial system; including 
guidewire, contrast dye, introduction sheath, specimen collection, lab work, x-rays of chest and leg arteries, 
COVID-19 test, electrocardiograms, and sedation for date of service September 22, 2022. 
 
You asked the Plan to pay for the selective catheter placement, arterial system; including guidewire, contrast 
dye, introduction sheath, specimen collection, lab work, x-rays of chest and leg arteries, COVID-19 test, 
electrocardiograms, and sedation. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the documentation does not support medical necessity.  
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. Review of the file shows that no medical records were provided for 
the services rendered. Without medical records, medical necessity is not supported. Based on this information, 
we decided that Medicare rules for coverage of the selective catheter placement, arterial system; including 
guidewire, contrast dye, introduction sheath, specimen collection, lab work, x-rays of chest and leg arteries, 
COVID-19 test, electrocardiograms, and sedation have not been met. Therefore, we decided that the Plan does 
not have to pay for the selective catheter placement, arterial system; including guidewire, contrast dye, 
introduction sheath, specimen collection, lab work, x-rays of chest and leg arteries, COVID-19 test, 
electrocardiograms, and sedation for date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care with an out-of-network (OON) long-term COVID-
19 treatment clinic.  
You asked the Plan to pre-approve care with an OON long-term COVID-19 treatment clinic. You say that the 
Plan is only offering care with one-hour, once-a-month online classes. You say that the requested OON 
provider knows more about your symptoms and treatment availability. You say that the requested OON 
provider has a better grip on staffing issues and updated protocols.  The Plan denied your request. The Plan 
says treatment of your condition is available in-network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that prior authorization is 
required for any services that are not available from Plan Providers.   
 
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 care with an OON long-term COVID-
19 treatment clinic. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found that the Plans denial is medically justified because they are offering adequate care to 
meet your medical needs through referral to network providers. The records provided do not indicate anything 
unique about your condition that would make it medically necessary to see the requested OON provider. The 
Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of 
your condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of care with an OON long-term COVID-19 treatment clinic have not been met. 
Therefore, we decided that the Plan does not have to pre-approve care with an out-of-network (OON) long-
term COVID-19 treatment clinic.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion (96365, 96366), refilling and 
maintenance of portable pump (96521), diabetes outpatient self-management training services (G0108) and 
insulin for insulin pump use (J1817) provided on March 27, 2023. 
 
You asked the Plan to pay for intravenous infusion and other services. You say that you are requesting 
reconsideration and ask for review of the medical records attached. The Plan denied your request. The Plan 
says the submitted codes are not appropriate for service billed, and the codes are not supported in the medical 
records submitted. 
 
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 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 intravenous infusion and other services. Our reviewer says 
that the service is not medically necessary. Our reviewer found the codes in question are not supported by the 
medical record. The record states that a continuous insulin infusion was performed with guidance by glucose 
measurements. According to CPT rules, there is a more specific code to report this procedure. Services are not 
coded to the highest level of specificity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion and other services. have not been met. Therefore, we 
decided that the Plan does not have to pay for intravenous infusion (96365, 96366), refilling and maintenance 
of portable pump (96521), diabetes outpatient self-management training services (G0108) and insulin for 
insulin pump use (J1817) provided on March 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab (Mvasi) and cobimetinib. 
 
You asked the Plan to pre-approve bevacizumab (Mvasi) and cobimetinib. You say that the enrollee is 
experiencing progressive neuropathy secondary to nab-paclitaxel. You say that you are recommending this 
regimen for the future. You also say that this could prolong the enrollee's survival.  The Plan denied your 
request. The Plan says the requested drug regimen is considered experimental and investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bevacizumab (Mvasi) and cobimetinib. 
Our reviewer says that the requested use of bevacizumab (Mvasi) and cobimetinib is not medically necessary. Our physician reviewer found the requested use of bevacizumab (Mvasi) and cobimetinib is not Food and Drug 
Administration-approved for the enrollee's diagnosis. The reviewer also found that the use of bevacizumab 
(Mvasi) and cobimetinib is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of these 
drugs 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 bevacizumab (Mvasi) and cobimetinib have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bevacizumab (Mvasi) and cobimetinib.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair (K0001x30 units) provided on 
November 22, 2022, to December 21, 2022. 
 
You asked the Plan to pay for a standard wheelchair. You say that the procedure code listed above is a monthly 
rental and should not be considered as multiple units. The provider has submitted supporting documentation for 
reconsideration of denied code. The Plan denied your request. The Plan says code K0001 remains not 
supported. The documentation submitted does not support the number of units billed, therefore, the billed 
service cannot be verified. 
 
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 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 a standard wheelchair. Our coding reviewer says that the 
service is not medically necessary. Our coding reviewer found that the record does not support thirty (30) units 
of K0001. The information in the case file states that one wheelchair was provided as a rental, which is one (1) 
unit. Units billed of K0001 are not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pay for a standard wheelchair (K0001x30 units) provided on November 22, 2022, to 
December 21, 2022.