Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the single vision lens, the tint, the 
polycarbonate lens, and the anti-reflective coating provided on June 28, 2023. 
 
You asked the Plan to pay for the deluxe frames, the single vision lens, the tint, the polycarbonate lens, and the 
anti-reflective coating. You say that you were told by the provider that the glasses were covered. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $300 benefit toward the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the $300 allowance was deducted from the submitted 
claim. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames, the single 
vision lens, the tint, the polycarbonate lens, and the anti-reflective coating have not been met. Therefore, we 
decided that the Plan does not have to pay for the deluxe frames, the single vision lens, the tint, the 
polycarbonate lens, and the anti-reflective coating provided on June 28, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health care provided from February 8, 2023, to March 9, 2023. 
 
You asked the Plan to pay for home health care. You say that this claim was submitted per Medicare 
guidelines. The Plan denied your request. The Plan says that when more than one line on a home health claim 
reports Q5001, Q5002, or Q5009, the same code must not be reported on consecutive dates of service. 
 
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 denied payment for this claim solely on the basis that code Q5001 was 
billed on consecutive dates on the claim. However, code Q5001 was billed on dates of service February 8, 2023 
and March 2, 2023, which are not consecutive dates. Therefore, the Plans denial rationale is not supported. 
The Plan did not provide any other rationale or evidence to support a denial of payment for this claim. 
Therefore, we decided that the Plan has to pay for home health care provided from February 8, 2023, to March 
9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace and sleeve purchased on July 14, 2023, under 
the supplemental over-the-counter benefit. 
 
You asked the Plan to pay for the knee brace and sleeve. You say that the items should be covered under your 
supplemental plan. The Plan denied your request. The Plan says the items were not purchased from an 
approved provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee brace and sleeve under the Plans supplemental over-the-counter benefit have not been 
met. Specifically, the items were not purchased through the Plans approved vendors. Therefore, we decided 
that the Plan does not have to pay for the knee brace and sleeve purchased on July 14, 2023, under the 
supplemental over-the-counter benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 06, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 10% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 10% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on February 06, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 81218, 81209, and 81272. 
We decided that the Plan does not have to pay for the services described by procedure codes 81162, 81201, 
81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334.  
 
You asked the Plan to pay for the lab testing billed for date of service May 24, 2023. You say that the treatment 
sought was medically necessary. The Plan says that one code must be submitted for the panel. 
 
We decided that the Plan has to pay for the services described by procedure codes 81218, 81209, and 
81272.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 81218, 81209, and 81272 billed 
for date of service May 24, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure codes 81162, 
81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81334. 
 
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. 
 
The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
NGS panel that was not billed with a panel code as required. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
and 81334 billed for date of service May 24, 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 GeneSight Psychotropic testing (0345U, 81291) provided 
August 1, 2023. 
 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 the claim for pharmacogenomics testing does not appear 
to meet Medicare coverage criteria and is not medically necessary.  
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has diagnoses of attention deficit hyperactivity disorder, other type, unspecified 
mood (affective) disorder, and anxiety disorder. The Current Outpatient Medications list on July 12, 2023, did 
not include any oral psychiatric medications. The available clinical documentation is insufficient to 
demonstrate that GeneSight Psychotropic genetic testing is medically reasonable and necessary for the enrollee 
in this case. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for GeneSight Psychotropic testing (0345U, 81291) provided August 1, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve the medication. You say that you need to take three medications for the 
pain. The Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
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 reviewer says that 
the criteria for coverage of Gelsyn-3 have not been met. Our physician reviewer found that the Plan requires a 
trial of one of the alternatives Monovisc, Orthovisc, Synvisc or Synvisc-One before they will approve the 
requested drug. In this case, you have not tried and failed one of the required drugs. There is no documentation 
provided indicating that the Plan's required drugs would likely be less effective or likely have adverse effects. 
 
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 Gelsyn-3.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for June 23, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20610 
provided on June 23, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for 
June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 87493 and 87801 provided on 
November 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. 
 
In this case, we have confirmed that code 87493 is a column II code to column I code 87493. This claim has 
not been billed with an appropriate modifier to bypass the edit. In addition, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. This means 
code 87801 is not payable as billed. Therefore, we decided that the Plan does not have to pay for lab services 
billed with codes 87493 and 87801 provided on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition billed with codes B4189, B4224, 
B4220 and B4185 for July 19, 2023, to July 25, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 parenteral nutrition billed with codes B4189, B4224, 
B4220 and B4185 for July 19, 2023, to July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861, 95865, and 95868 billed for date of 
service June 21, 2022.  
 
You asked the Plan to pay for procedure codes 95861, 95865, and 95868. You say that you disagree with the 
Plan's denial. 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 codes 95861, 95865, and 95868 is 1. The MAI value for this code is 3. You 
billed 2 units of each of these codes, 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, 95865, and 
95868 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95861, 
95865, and 95868 billed for date of service June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services provided from 
April 3, 2023, through April 19, 2023.  
 
You asked the Plan to pay for the ESRD services. You say that you feel that this claim was denied incorrectly.  
The Plan denied your request. The Plan says this claim was not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that ESRD claims for AKI patients must be billed 
with condition code 84 and CPT code G0491. 
 
We looked at the file and Medicare rules. In this case, the claim has condition code 84 reported, meaning this is 
for AKI services. However, the required CPT code G0491 was not billed for these services. Based on this information, we decided that Medicare rules for coverage of the ESRD services have not been met. Therefore, 
we decided that the Plan does not have to pay for the end-stage renal disease (ESRD) services provided from 
April 3, 2023, through April 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for procedure code S9338. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee has right tenderness in the 
genicular nerve region with diminished reflexes. You say that the enrollee has had a previous injection in 2016 
with reported improvement. The Plan denied your request. The Plan says this is experimental and therefore is 
not covered. 
 
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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental for the treatment of knee pain. Therefore, the reviewer 
found that the requested genicular nerve block is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 for date of service September 2, 2022. 
 
You asked the Plan to pay for procedure code 83520. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
In this case, the CPT Code Manual definition of code 83520 is Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, this code represents not 
otherwise specified code. However, a complete description of the not otherwise specified code was not 
included. The order/lab requisition/claim must include what laboratory test was ordered/requested to validate 
the code billed. Based on this information, we decided that Medicare rules for coverage of procedure code 83520 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 83520 
for date of service September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 24, 2022, to August 
22, 2022. 
 You asked the Plan to pay for the home health services. You say that your organization provided quality care to 
the enrollee, and these services were medically necessary. 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 July 24, 2022. The NOA was not received by the Plan until April 27, 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 
July 24, 2022, to August 22, 2022.