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 December 11, 2022, billed 
with codes 81292, 81295, 81298, 81317, & 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 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 
December 11, 2022, billed with codes 81292, 81295, 81298, 81317, & 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service January 26, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that the claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is two (2). The MAI value for this code is 3. You billed six (6) units 
of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99458 billed for date of service January 26, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that you are asking for Injectafer because it is a higher 
dose requiring less infusions, since the enrollee is actively bleeding. You also say that Injectafer is appropriate 
and medically necessary for the enrollee. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Injectafer. Our reviewer says that the 
enrollee does not meet the coverage criteria for Injectafer. Our physician reviewer found the Plan requires a 
trial of  Venofer (iron sucrose) before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drug. Our reviewer also found that there is no documentation provided indicating 
that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 21, 2022, to 
November 19, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided a Request for 
Anticipated Payment (RAP), so this claim should be processed. The Plan denied your request. The Plan says 
the NOA was not received. 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, you have not submitted the required NOA. You provided a RAP.  However, according to Medicare 
rules, RAPs are not appropriate for services in 2022- you need to provide the required NOA instead. Therefore, 
we decided that the Plan does not have to pay for home health services provided from October 21, 2022, to 
November 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service May 10, 
2022.   
You asked the Plan to pay for procedure code 95861. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter (E1399) provided July 22, 2022 to 
September 17, 2022. 
 
You asked the Plan to pay for the power scooter (E1399). You say that this equipment was medically 
necessary. The Plan denied your request. The Plan says the power scooter was used outside the home and is not 
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a power scooter (E1399) provided July 22, 2022 to September 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the hereditary cancer panel (81432, 81433) provided on 
November 21, 2022. 
 
You asked the Plan to hold you harmless for the hereditary cancer panel. You say that you have already paid a 
lot of money for your cancer treatment, and you were not aware these tests were being done. You feel your 
provider should have verified they would be covered, and you should not be responsible. The Plan denied your 
request. The Plan says that there are insufficient medical records to support these services, which were 
performed by an out-of-network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also 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. 
 
You were referred for the hereditary cancer panel by your provider. The Plan does not clarify or show any 
evidence that they attempted to verify that the referring provider was a network provider. Based on Medicare 
rules, we can presume that the referring physician is a network provider. The file does not show that the Plan 
provided notice that the hereditary cancer panel would not be covered. Under Medicare rules, this means the 
hereditary cancer panel is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the hereditary cancer panel (81432, 81433) provided on November 21, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of tumor provided on October 19, 2021. 
 
You asked the Plan to pay for excision of tumor. You say that you want the Plan to pay for the service. The 
Plan denied your request. The Plan says the claim was received more than one year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for excision of tumor was not filed until November 1, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for excision of tumor provided on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition requires an IRF admission. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission. 
 
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 enrollee does 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 4, 2023. 
 
You asked the Plan to pay for code 99285. You say that the complexity of the patient's care warranted the 
billing of code 99285. The Plan denied your request. The Plan says the medical records do not support the 
billing of code 99285. The Plan has downgraded this claim to code 99284. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: a comprehensive history; 
a comprehensive 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found the enrollee was a then 93-year-old female with a history 
of dementia who presented to the emergency room on January 4, 2023, with mental status changes. She was 
evaluated and found to have a pneumonia and rated controlled atrial fibrillation. She was treated with IV 
antibiotics and admitted. The enrollee was hemodynamically stable. The documentation did not support 
procedure code 99285. Specifically, there was no 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve dexamethasone.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0241U for date of service 
February 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0241U 
for date of service February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on December 
20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to regain maximum function and continue a multi-disciplinary approach to care. The Plan denied 
your request. The Plan says the enrollee's records do not show that they need continued treatments and care 
than can only be given in a hospital setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 74176 billed for date of service December 
6, 2022. 
 
You asked the Plan to pay for procedure code(s) 74176. You say that this charge was appropriate for the level 
of acuity and intensity of the medical services provided. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 74176. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 74176. Based on this information, 
we decided that Medicare rules for coverage of procedure code 74176 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 74176 billed for date of service December 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite strips. 
 
You asked the Plan to pre-approve FreeStyle Lite strips. You say that the enrollee's mother checks their blood 
sugar for them. You also say that these have been the easiest test strips for the enrollee's mother to use. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration for vaccines/toxoids provided 
on September 6, 2022. 
 
You asked the Plan to pay for immunization administration for vaccines/toxoids. You say that you believe that 
the Plan's policy that the Mpox is only reimbursable when there is documented exposure is outdated. The AMA 
references administrating Mpox vaccine to high-risk individuals and not just those exposed, per CDC 
guideline. The Plan denied your request. The Plan says vaccinations or inoculations are excluded as 
immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or 
condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, 
or immune globulin. In the absence of injury or direct exposure, preventive immunization 
(vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. In cases 
where vaccination or inoculation is excluded from coverage, related charges are also not covered. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
administration for vaccines/toxoids. The Plan follows the same rules.  
 
Records do not show that the enrollee has been injured or directly exposed to any illness related to 
immunization administration for vaccines/toxoids. Therefore, we decided that the Plan does not have to pay for 
immunization administration for vaccines/toxoids provided on September 6, 2022.