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

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on November 21, 
2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99226) provided on June 3, 2022. 
 
You asked the Plan to pay for physician services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 99226 is subsequent observation care for the evaluation 
and management of a patient, requiring two out of these three key components: a detailed interval history, a 
detailed examination and medical decision making of high 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 physician services. Our reviewer says that the records do not 
support the code billed. Our reviewer found the medical records submitted did not support a detailed interval history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician services have not been met. Therefore, we decided that the Plan does 
not have to pay for physician services (99226) provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 4, 2022. 
 
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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
February 4, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97530 rendered on October 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this code is not separately reportable according to incidental/mutually exclusive edits. 
 
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. The plan has not stated which code CPT 97530 is incidental to in this case. The 
only other code visible on the claim for the same date is CPT 97110, which does not have an edit with CPT 
97530. Therefore, we decided that the Plan has to pay for procedure code 97530 rendered on October 13, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the powered upper extremity orthosis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found use of this orthosis is considered experimental for the patient's condition. More 
studies are needed to show safety and efficacy.  
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that please see the attached medical records. The 
Plan denied your request. The Plan says the request to continue using a device to assist with breathing 
(noninvasive ventilator or NIV) coded as E0466 does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent 
to chronic obstructive pulmonary disease. The records document that the home ventilator is being requested for 
use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be 
provided by a BiPAP device with AVAPS and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level 
CPAP therapy for conditions described in this respiratory assist device (RAD) policy will be denied as not 
reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet evidenced-based criteria. 
 
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 requested services. Our physician 
reviewer found that the magnetic resonance imaging does not show modic endplate changes. The cause of back 
pain is not clear. Therefore, the request is not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on February 18, 2022. 
 
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 that the services were part of a clinical trial. 
 
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. The Plan states that the services were part of a clinical trial; however, there is no 
documentation to support this as fact. The Plan has not provided any binding Medicare rules or documentation 
to support that the services are not covered as billed. Therefore, we decided that the Plan has to pay for the 
laboratory services rendered on February 18, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for November 14, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Billed code 99153 has a PC/TC indicator of 3 and no separate PC 
payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
November 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pelvic ultrasound (76857) provided on September 12, 2022. 
 
You asked the Plan to pay for a pelvic ultrasound. You say that you want the Plan to reconsider payment. The 
Plan denied your request. The Plan says they did not receive a primary carriers Explanation of Benefits.  
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the explanation of benefits (EOB) from the primary payer. As the secondary insurer, the Plan cannot be held 
responsible for a pelvic ultrasound until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for a pelvic ultrasound (76857) provided on September 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an air mattress (E0277). 
 You asked the Plan to pay for the air mattress. You say that this mattress is medically necessary. The Plan 
denied your request. The Plan says coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a group 2 support surface is covered for a 
beneficiary with pressure ulcers or a myocutaneous flap or skin graft. 
 
We looked at the file and Medicare rules. The records show no history of pressure sores or wounds. Based on 
this information, we decided that Medicare rules for coverage of the air mattress have not been met. Therefore, 
we decided that the Plan does not have to pay for an air mattress (E0277).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn injections. 
 
You asked the Plan to pre-approve Gelsyn injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this Part B drug is not covered when supplied by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gelsyn injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 3 continuous glucose monitor (CGM) 
sensors (A4239). 
 
You asked the Plan to pre-approve Freestyle Libre 3 CGM sensors. You say that you disagree with the denial. 
The Plan denied your request. The Plan says a FreeStyle Libre 3 is not currently eligible for Medicare 
reimbursement. Smart devices are non-covered by Medicare because they do not meet the definition of DME. 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve Freestyle Libre 3 continuous glucose monitor (CGM) sensors (A4239).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 1, 2022 to April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 1, 
2022 to April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on August 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says the system is considered experimental and unproven. 
 
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 requested services. Our physician 
reviewer found that the records do not contain imaging that shows only modic endplate changes without facet 
degenerative joint disease or foraminal stenosis. Therefore, the requested service is not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64495 provided on December 27, 2022. 
 
You asked the Plan to pay for procedure code 64495. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for procedure code 64495 based on Medicare criteria. The Plan denied payment for this 
service due to the provider not submitting documentation showing the 3rd level was provided under medically 
necessary unique circumstances. However, there is no evidence that the Plan requested records beyond the 
procedure/operative note that was provided for review. These records are needed to determine if the 3rd level 
was medically necessary. Therefore, we decided that the Plan has to pay for procedure code 64495 provided on 
December 27, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 05, 2022, to 
November 28, 2022. 
 
You asked the Plan to pay for nursing facility care. 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 nursing facility care 
provided on November 05, 2022, to November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99056 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 99056. You say that the services were billed correctly. The Plan 
denied your request. The Plan says procedure code 99056 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99056 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99056 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99056 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99056 billed for date of service November 28, 2022.