Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital bed, semi-electric (head and foot adjustment), with 
any type side rails, without mattress (E0261) provided to the enrollee on February 7, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says payment is not allowed for this service because the procedure code billed is missing a required 
modifier. The Plan states a correct claim can be submitted to the claims address on the back of the member's 
identification care with the required modifier for claim reconsideration. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. A hospital bed must be reported with 
modifier KX, GA or GZ to indicate whether or not coverage criteria have been met. None of these modifiers 
are present on the claim, therefore, the claim denied correctly and will be upheld. 
 
 
Therefore, we decided that the Plan does not have to pay for hospital bed, semi-electric (head and foot 
adjustment), with any type side rails, without mattress (E0261) provided to the enrollee on February 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for aspiration of the right hip joint with related fluoroscopic imaging 
guidance provided on January 3, 2020. 
 
You asked the Plan to pay for the hip joint aspiration and related guidance. You say that there is no rule that 
supports this denial. The Plan denied your request. The Plan says that according to our policy, procedure 
20610, must be reported with certain diagnoses in order to meet coverage 
criteria. 
 
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's only rationale for this denial is that code 20610 must be reported with 
certain diagnoses to meet coverage criteria. No citation to any rule or regulation was provided to support that 
only certain diagnosis codes can be used with this code. We found no Medicare rule that limits coverage 
of this code to a set of covered diagnoses. Review of the record shows that a sample from the artificial hip joint 
was taken to check for infection. No argument was made by the plan that this is not medically reasonable. 
Without a valid rationale to support its decision, we find that the non-payment for codes 20610 and 77002 is 
not substantiated. Therefore, we decided that the Plan has to pay for aspiration of the right hip joint with related 
fluoroscopic imaging guidance provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
January 2, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0650) provided to the enrollee on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 9, 2020. 
 
You asked the Plan to pay for the testing services. You say that the provider ordered the testing to determine if 
there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says coverage 
of comprehensive genomic profile testing is limited to one test per specimen. 
 
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 looked at the file and the rules. We find that the claim provided does not show that the Medicare coding 
and billing guidance for the testing at issue has been followed. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the testing provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee 
on December 6, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthoses have not been met. Documentation submitted did not 
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be 
verified. Therefore, we decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) 
provided to the enrollee on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 9, 2020 to March 
11, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient hospital level of care is 
medically necessary, reasonable and appropriate. The Plan denied your request. The Plan says that the records 
do not support medical necessity for inpatient hospitalization. The plan approved for the emergency room and 
hospital observation services once a corrected claim is received. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 9, 2020 to March 11, 2020.  
 
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 the drug testing coded G0483 provided on August 15, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 code G0483 is not supported in the medical record. Specifically, the documentation did not 
include a valid physician order/lab requisition form or medical records signed by the ordering physician stating 
exactly what tests were to be performed. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0483 provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 5, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) and adjunctive procedure (D9999) provided on January 14, 2020.
You asked the Plan to pay for the application of desensitizing medicament and adjunctive procedure. You say that these services were necessary due to your face and jaw being swollen. You also say that you had an infection and material under your bridge, and were told to take medication twice a day. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) and adjunctive procedure (D9999) provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 17, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the treating physician to 
determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. The 
Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 17, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT, head or brain; without contrast material (70450)
provided to the enrollee on April 20, 2020.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.
Procedure code 70450 was denied as the column II code to the column I computed tomographic angiography,
head, with contrast material(s), including non-contrast images, if performed, and image postprocessing (CPT
Code 70496). Per review of medical records, documents received supports CPT code 70450 being performed as
a separate and distinct services performed during a different session by the denied provider but an appropriate
modifier has not been appended. Therefore, we decided that the Plan does not have to pay for CT, head or
brain; without contrast material (70450) provided to the enrollee on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 20, 2020. 
 
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 was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nasal hemorrhage control (30903) provided on September 
11, 2019. 
 
You asked the Plan to pay for the nasal hemorrhage control. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation does not support that 
this service was performed bilaterally. 
 
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 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 the nasal hemorrhage control. Our reviewer says that CPT 
code 30903 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include documentation to validate that a Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method was performed bilaterally on the billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nasal hemorrhage control have not been met. Therefore, we decided that the 
Plan does not have to pay for nasal hemorrhage control (30903) provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane for the enrollee. 
 
You asked the Plan to pre-approve Abraxane. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the accepted use of Abraxane requires that it will be used as first-
line therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Abraxane. Our reviewer says that 
Abraxane is not medically reasonable and necessary for the enrollee in this case. Abraxane monotherapy is 
being requested to treat performance status 1 enrollee who has not been previously treated for non-small cell 
lung cancer (NSCLC.) Abraxane is not FDA approved for use as monotherapy in this setting. The drug is not 
supported as monotherapy for this use in patients with performance status of 1. There are no supporting 
citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any 
of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for coverage of Abraxane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office or other outpatient visit for the 
evaluation and management of a new patient (99203) and fluoroscopy (separate procedure), up to 1 hour 
physician or other qualified health care professional time (76000) provided on December 12, 2019 by an out-
of-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that you were approved by the Plan for 
the services and you should not have to pay this much for your cost-share. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received specialist office services and imaging provided on December 12, 
2019 from an out-of-network provider. You were approved for the services to be provided by an out-of-
network provider; however, you are still responsible for the cost-share. You are asked to pay a $30 copayment 
for the specialist office visit. Your EOC says that enrollees must pay a $30 copayment for services obtained 
from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician?s assistant or 
other non-physician health care professionals in a specialist?s office (as permitted under Medicare rules). 
Furthermore, the Medicare-allowed amount for the imaging is less than the set $75 copayment; therefore, you 
have been asked to pay the lesser amount of $49.51 for the imaging. Your EOC says that enrollees must pay a 
$75 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in 
a physician?s office or at a free-standing facility. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
office or other outpatient visit for the evaluation and management of a new patient (99203) and fluoroscopy 
(separate procedure), up to 1 hour physician or other qualified health care professional time (76000) provided 
on December 12, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve pneumatic compression devices and related supplies. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says that you 
do not have lymphedema or chronic venous insufficiency with ulcers. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
The file shows that a segmental pneumatic compressor with and without calibrated gradient pressure (E0651 
and E0652), and a segmental pneumatic appliance for use with a pneumatic compressor (E0667) were 
requested. 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 items. Our 
physician reviewer found that you have severe lymphedema. You have had physical therapy sessions that have 
not been successful. As you have failed protracted outpatient therapy, the requested items are indicated in the 
setting of failed line of therapy. Therefore, the requested services are medically 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 requested items have been met. Therefore, we decided that the Plan has to 
pre-approve pneumatic compression devices and related supplies.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol Hcl for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Tramadol Hcl for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.