Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an 
IRF. 
 
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 pay for the services provided on December 2, 2019, to December 5, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services is included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services provided on December 2, 2019, to 
December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (HCPCS Q9958) provided to the enrollee 
on February 7, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the NDC number submitted with the claim is for a multi-use vials purpose. 
 
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 HCPCS code Q9958 is "High osmolar contrast material, up to 
149 mg/ml iodine concentration, per ml. 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the claim 
submitted reflects NDC number 0270-0149-57 which is for 10 BOTTLE in 1 PACKAGE > 300 mL in 1 
BOTTLE. This is a multi-use vial and is not subject to reimbursement for discarded amounts of drug or 
biological. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (HCPCS Q9958) provided to the enrollee on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic spinal manipulation (98941) and mechanical
traction therapy (97012) provided on January 30, 2020.
You asked the Plan to pay for chiropractic spinal manipulation and mechanical traction. You say that this
should be covered. The Plan denied your request. The Plan says medical records were not submitted for these
services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The Plan offers a supplemental chiropractic benefit
for services designed to help relieve pain, inflammation, swelling, and /or leg and foot numbness. The rules
also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier
sufficient information to determine whether payment is due and the amount of payment.
No medical records were submitted to show whether the criteria for Medicare-covered chiropractic services or
the Plan's supplemental chiropractic benefit have been met. Without this information, these services cannot be
covered. Therefore, we decided that the Plan does not have to pay for chiropractic spinal manipulation (98941)
and mechanical traction therapy (97012) provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 8, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
reported with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99213) and electrical stimulation 
(G0283) provided from December 6, 2019 to December 20, 2019. 
 
You asked the Plan to pay for a chiropractic office visit and electrical stimulation. You say that these services 
should be covered. The Plan denied your request. The Plan says these services are not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99213) and electrical stimulation (G0283) provided 
from December 6, 2019 to December 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the MRI provided on September 26, 2019. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that you do not feel that you owe the Plan 
any copayment amount. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 20% for 
coinsurance for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $49.74 which is 20% of the allowed amount for the MRI. The allowed amount is 
$248.69. ($248.69 x 20% = $49.74). The MRI falls 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. Therefore, we decided that the Plan does not have to waive the coinsurance for the MRI 
provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were not anticipating this cost 
share. You say you are on a fixed income. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $150 
copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls 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. Therefore, we decided that the Plan does not have to waive 
the copayment for the CT scan provided on May 14, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally medically stable and the 
documentation does not support that he has complex medical issues that require acute rehab nursing care, or 
monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee 
may benefit from continuing physical therapy (PT) and occupational therapy (OT), the documentation does not 
support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee wrap (non-covered item or service, A9270) provided on 
January 31, 2020. 
 
You asked the Plan to pay for the knee wrap. You say that this equipment should be covered because it was 
essential to your healing. The Plan denied your request. The Plan says this item is not covered under Medicare 
or the Health Plan. 
 
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 knee wrap have not been met. The rules say that brace sleeves 
(A9270) used in conjunction with orthoses are noncovered because they are not used to support a weak or 
deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does 
not meet the definition of a brace). Therefore, the knee wrap (non-covered item or service, A9270) is not 
covered. Therefore, we decided that the Plan does not have to pay for knee wrap (non-covered item or service, 
A9270) provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that the requested items are necessary. The Plan denied 
your request. The Plan says the items are not primarily medical in nature. Therefore, coverage criteria has not 
been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on January 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The submitted documentation does not contain medical records for 
the date of service in question. Without records, it cannot be determined that Medicare Coverage Criteria have 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on 
January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic office visits (99202) and electrical stimulation 
(97032) provided from April 22, 2020 to May 1, 2020. 
 
You asked the Plan to pay for chiropractic office visits and electrical stimulation. You say that you did not 
know these services would not be covered. The Plan denied your request. The Plan says these services are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic office visits (99202) and electrical stimulation (97032) provided 
from April 22, 2020 to May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) 
and sleeves. 
 
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that you cannot walk 
due to swelling. The Plan denied your request. The Plan says that the records received indicate you have not 
tried a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you have had at least four 
weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic 
compression device (E0652) and sleeves.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elective aortic aneurysm repair to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve an elective aortic aneurysm repair to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an elective aortic aneurysm repair to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for special pump services (CPT 99190) provided on February 
21, 2020. 
 
You asked the Plan to pay for the special pump services. You say that the service in dispute was for the setup 
and operation of the Heart Lung machine for the enrollee's open heart surgery. You say that it takes a half hour 
to an hour to set up the Heart Lung machine. You say that the perfusionist is required to be in the operating 
room during the length of the procedure. You say that, per the hospital protocol, it is mandatory that the 
surgeon, anesthesiologist and perfusionist transport the enrollee to the unit and be there unti lthe enrollee is in 
stable condition. The Plan denied your request. The Plan says there is documentation supporting 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for special pump services (CPT 
99190) provided on February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2020. 
 
You asked the Plan to pay for the Guardant360 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 a covered benefit. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z Code identifier adjacent to the CPT code 81479 in 
the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 26, 2020.
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 Guardant360 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 the Guardant360 testing is not supported in the medical record. Specifically, this service required 
the use of CPT 81479. In addition, the appropriate DEX Z Code identifier must be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided to the enrollee from 
December 5, 2019 through January 16, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that the claims should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 home infusion therapy have not been met. S codes (temporary 
codes) are used to report drugs, services and supplies for which there are no national codes. These codes are 
primarily used by private insurers for claim processing, policies or programs. These codes are not payable by 
Original Medicare (OM). S9328 is listed as status "I" on the CMS Medicare Physician Fee Schedule. Status I= 
Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided to the 
enrollee from December 5, 2019 through January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 2, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 2, 2020 billed with multiple line items of 
different CPT codes.