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

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 
81407, 81480, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached documents, 
review and reconsider the claim for payment. 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 
November 16, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81403, 81404, 81405, 81406, 81407, 81480, 81479.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on March 03, 
2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that you are requesting a 
reconsideration of the denied charges. 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 an outpatient mental 
health visit provided on March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. 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 an office visit provided 
on March 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; single view (71045) 
transportation of portable x-ray equipment and personnel to home or nursing home (R0070) set-up portable x-
ray equipment (Q0092) provided January 16, 2023. 
 
You asked the Plan to pay for the portable x-ray services. You say that kindly reprocess the claim for payment 
and don't just reprocess again as out of network as the provider rendered services in good faith. 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 $950 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.   
The item or service you asked the Plan to pay for falls within the Outpatient diagnostic tests and therapeutic 
services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $950 deductible which applies to Outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time the portable x-ray 
services was received on January 16, 2023. Therefore, we decided that the Plan does not have to pay for 
radiologic examination, chest; single view (71045) transportation of portable x-ray equipment and personnel to 
home or nursing home (R0070) set-up portable x-ray equipment (Q0092) provided January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic (81291, 81226) provided on 
February 14, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of the denied 
services The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Also, the diagnostic code F31.76 for bipolar disorder, in full remission, is not listed on the 
list of codes that support medical necessity per Local Coverage Article (LCA) on Pharmacogenomics Testing 
(A58324). 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 GeneSight Psychotropic (81291, 81226) provided on 
February 14, 2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
17, 2021, to December 16, 2021. 
 You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not qualify for SNF coverage. The enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs were custodial and could, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 17, 2021, to December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 18, 2023, to January 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were only 
supposed to be in the hospital for 1 day. 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 $290 
copayment per day, for days 1 to 6 and a $0 copayment after day 6 of each in-network Medicare-covered stay.  
 
 You have been asked to pay a $290 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $580 ($290 copayment x 2 days = $580). 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 copayment for the inpatient 
hospital stay provided from January 18, 2023, to January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72040, 99244, 74230, 70100) provided 
on January 27, 2023. 
 
You asked the Plan to pay for the radiology 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 72040, 99244, 74230, & 70100 are not supported in the medical record. Specifically, 
the claim was billed with place of service 11, however records show that this procedure was performed in a 
mobile setting at a Skilled Nursing Facility, not at an outpatient or office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for radiology services (72040, 99244, 74230, 70100) provided on January 
27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an ultralightweight wheelchair (K0005) 
 
You asked the Plan to pre-approve the wheelchair. You say that you need this wheelchair as soon as possible 
and have requested it because you need help moving around. You also say that a wheelchair is beneficial for 
you and is needed for multiple reasons.  The Plan denied your request. The Plan says your request is not 
medically necessary because your records do not show that you had a mobility limitation, that you were unable 
to use a cane/walker, or that you had a specialty evaluation.  
 
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 wheelchair. Our physician reviewer 
found the documentation available for review does not support that you require an ultralight manual wheelchair 
to accomplish mobility related self-care tasks in the home. There is no indication they are unable to use an 
alternative assistive device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve  an ultralightweight wheelchair (K0005)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable gaseous oxygen system and oxygen 
concentration (E1390-RR-KX, E0431-RR-KX) provided from February 5, 2023, through March 5, 2023. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the claim should be paid. 
The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The billed service has been 
denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note. 
Based on this information, we decided that Medicare rules for coverage of the durable medical equipment 
(DME) have not been met. Therefore, we decided that the Plan does not have to pay for the portable gaseous 
oxygen system and oxygen concentration (E1390-RR-KX, E0431-RR-KX) provided from February 5, 2023, 
through March 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement procedures on the skin provided on January 31, 
2023. 
 
You asked the Plan to pay for debridement procedures on the skin. You say that the records attached support 
the services provided. 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 debridement procedures 
on the skin provided on January 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network electrocardiogram (EKG) 
provided on March 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network electrocardiogram (EKG). You say that this was 
a screening test and should have a $0 copayment. 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 outpatient hospital. 
 
You have been asked to pay a $40 copayment for an in-network electrocardiogram (EKG). This item/service 
falls within the outpatient hospital 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 in-network electrocardiogram (EKG) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that genicular nerve ablation is medically 
necessary. The Plan denied your request. The Plan says genicular nerve ablation is  
experimental /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 genicular nerve ablation. Our reviewer 
says that the requested genicular nerve ablation is not considered medically reasonable and necessary. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve 
radiofrequency ablation of the right knee 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 14, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not think you should 
be responsible for this copayment. 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 $45 
copayment for urgent care clinic visits. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the urgent 
care clinic 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 copayment for an urgent care visit 
provided on March 14, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) using ImediMed's L-Dex device (93702).  
 
You asked the Plan to pre-approve the service. You say that the enrollee is at high risk of developing 
lymphedema. You say that you believe the use of the ImediMed's L-Dex device is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says that  the requested service is considered experimental 
and investigational.  
 
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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that L-Dex testing device is an Food and Drug Administration (FDA)-cleared device that can 
detect changes in extracellular fluid before signs of secondary lymphedema. There are multiple studies 
demonstrating potential benefits including one by Shah et al., in a metanalysis of 2020 demonstrated that 
Bioimpedance spectroscopy should be considered for Breast Cancer Related Lymphedema (BCRL) screening 
to detect subclinical BCRL and reduce rates of chronic BCRL in high-risk patients who has had lymph nodes 
removed. Therefore, the service is 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 the service have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) using 
ImediMed's L-Dex device (93702).   
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (J3304).  
 You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has met all criteria except there is no documentation that 
they have had serious side effects or drug failure to a second injectable corticosteroid.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the Health Plans denial should be upheld. The enrollee is reported to have bilateral knee 
arthritis/osteoarthritis, in the setting of obesity. There is no evidence that the enrollee has tried RICE, exercise, 
weight loss, over-the-counter medications or prescription-strength nonsteroidal anti-inflammatory drug 
(NSAIDS). The enrollee has shown little improvement from four prior corticosteroid injections. It is unclear 
why an injection with a long-acting corticosteroid would be expected to be any more beneficial or successful 
for the enrollee. As such, the requested Zilretta is not shown to be medically necessary or reasonable. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 16, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
March 16, 2023.