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

 
We decided that the Plan does not have to pay for procedure codes 72170, 73030, and 96372 for date of service 
June 5, 2023. 
 
You asked the Plan to pay for procedure codes 72170, 73030, and 96372. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable 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 72170, 73030, and 96372 are not payable as billed. Specifically, codes 72170, 73030, 
and 96372 have a status indicator of Q1. Code 99284 was billed on the same claim, with the same date of 
service, with revenue code of 450. This gives code 99284 a status indicator of V (clinic or emergency 
department visit). Therefore, procedure code 72170, 73030 and 96372, which have a status indicator of Q1, are 
not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 72170, 73030, and 96372 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 72170, 73030, and 96372 for date of service June 5, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0242U billed for date of service May 24, 2023. 
 
You asked the Plan to pay for the billed service. You say that the date of service is accurate. The Plan denied 
your request. The Plan says that the date of service is the specimen collection date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. An exception is made for molecular pathology tests performed by a 
laboratory other than a blood bank. This requires that the DOS be reported as the date the testing was 
performed. The Plan has not demonstrated that the billed test does not meet one of the exceptions. Based on 
this information, we decided that Medicare rules for coverage of the billed service have been met. Therefore, 
we decided that the Plan has to pay for procedure code 0242U 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: 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 your physical therapy with home health is 
inadequate, and you need more therapy in order to regain full function. The Plan denied your request. The Plan 
says the notes do not show that your care specifically requires the involvement of a doctor in the field of 
Rehabilitation Medicine. The notes do not show that you have complex care needs that require a coordinated 
team approach. The notes do not show that you must have an intensive therapy program (3 hours a day, at least 
5 days a week) in order to improve self-care functioning.  
 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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mitochondrial Deoxyribonucleic acid (DNA) testing for 
Leber's hereditary optic neuropathy. 
 
You asked the Plan to pre-approve mitochondrial DNA testing for Leber's hereditary optic neuropathy. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 
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 pre-approve mitochondrial DNA testing for Leber's 
hereditary optic neuropathy. 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 had visual loss since 2012 
and had genetic testing in August 2022, which showed a positive pathogenic variant of Mt-TLG1, suggesting a 
mitochondrial DNA disorder. The literature states that current genetic testing methods are unable to detect 
mutations in all individuals with suspected mitochondrial disease, and there is no proven effective treatment for 
persons with a known mitochondrial disease. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mitochondrial DNA testing for Leber's hereditary optic neuropathy have not 
been met. Therefore, we decided that the Plan does not have to pre-approve mitochondrial Deoxyribonucleic 
acid (DNA) testing for Leber's hereditary optic neuropathy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast prostheses received on July 18, 2023. 
 
You asked the Plan to pay for the breast prostheses. You say that you would like to be reimbursed for these 
items. The Plan denied your request. The Plan says the services received are not covered when received by a 
provider that does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the breast prostheses received on July 
18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on February 1, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code to bill for this panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 13, 2023, and billed with codes 87801, 87481, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 13, 2023, and billed with codes 87801, 87481, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94729 billed for date of service January 
10, 2023. 
 
You asked the Plan to pay for procedure code(s) 94729. 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) 94729. 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) 94729. Based on this information, 
we decided that Medicare rules for coverage of procedure code 94729 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 94729 billed for date of service January 10, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered for certain 
indications. 
 
The file does not show that the enrollee meets criteria for the requested power wheelchair and accessories. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for an office visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception for out-of-network care. You say that all of your 
providers are affiliated with this facility and accept your insurance. You also say that the facility does not 
accept your insurance. The Plan denied your request. The Plan says there are network laboratories available to 
provide these services. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of out-of-network care have not been met. Therefore, we decided that the Plan does not have to pre-
approve an in-network exception for an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the iovera procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary to address pain due 
to the enrollee's limited treatment options. The Plan denied your request. The Plan says the request 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 pre-approve the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the iovera technology is a non-opioid and non-systemic treatment for blocking pain signals 
from peripheral nerves. The procedure is considered experimental/investigational and is not medically 
necessary for the treatment of chronic bilateral knee pain.  
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the iovera procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the radiation therapy services, and the 
supplies provided from May 9, 2023, to May 18, 2023. 
 
You asked the Plan to reduce the cost share for the radiation therapy services and the supplies. You say that the 
supplies should be covered under the radiation therapy. 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 $60 
copayment for in-network radiation therapy. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for in-network Medicare Part B drugs.  
 
You have been asked to pay a $60 copayment for each radiation treatment provided on May 9, 2023, May 11, 
2023, May 15, 2023, and May 18, 2023. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and supplies 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.  
 
You have also been asked to pay $60, which is less than 20% coinsurance of the allowed amount for each drug 
provided on May 9, 2023, May 11, 2023, May 15, 2023, and May 18, 2023. These items/services fall within the 
Medicare Part B prescription drugs 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 reduce the cost share for 
the radiation therapy services, and the supplies provided from May 9, 2023, to May 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxyzine capsule. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Hydroxyzine capsule.   
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: 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 requested IRF services are medically necessary. 
The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 13, 2023, and 
April 27, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that it is difficult to find a trauma therapist 
without having to tell your whole story all over again, which could re-traumatize you and make your therapy needs longer. The Plan denied your request. The Plan says the supervising provider has opted out of Medicare 
and the provider supplying direct treatment is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The rules also say that Medicare payment cannot be 
made to a provider that is not enrolled in the Medicare program. A Master of Social Work is not eligible to 
enroll in Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. This provider states that they were acting as a supervisor to a Licensed 
Master Social Worker (LMSW) who actually provided direct treatment. LMSWs are not eligible to enroll in 
Medicare. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
April 13, 2023, and April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decipher Prostate Genomic testing (81542, 88381) 
provided April 15, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee has prostate cancer and Decipher 
Prostate was ordered by their doctor to help guide them through the process of selecting appropriate treatment 
to achieve the best possible outcomes. The Plan denied your request. The Plan says this test is not considered 
medically necessary nor reasonable or necessary per Medicare's coverage guidelines.  
 
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 Decipher Prostate Genomic testing was not medically reasonable and necessary in this case. 
The LCD criteria have not been met. The records do not show that the enrollee has a life expectancy of greater 
than or equal to 10 years as required. 
 
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 the Decipher Prostate Genomic testing (81542, 88381) provided April 15, 2023.