Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services coded 99152 provided on January 18, 2020.You asked the Plan to pay forthe moderate sedation services. 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.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by thesame physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, this service cannot be billed. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services coded 99152 provided on January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not check sugar levels 4 times a day. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under 
certain medical indications.  
 
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 services. Our physician 
reviewer found that the enrollee is noted to have type 2 diabetes, for which he takes multiple medications. The 
records note both that the enrollee checks his blood sugar, and that he does not check his blood sugar. The 
same office note provides two different lists of medications, one of which includes an insulin sliding-scale 
(ISS), one of which does not. The office note closes with a plan that appears to change the previously noted ISS 
to a fixed dose insulin regimen. No blood sugar logs have been submitted for review. There is no evidence of 
how often the enrollee checks his blood sugar or how often such testing results in self-regulated adjustments to 
his insulin. Based on the documentation, it has not been shown that the use of a CGM is medically 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided. 
 
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 
billed 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.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your rehabilitation needs are not complex and do not require an 
interdisciplinary approach with multiple specialists to oversee your rehabilitation care. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and dehydration. 
Your medical problems are stable. There are no identified problems that need inpatient medical management. 
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. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. 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. Our physician 
reviewer found that your 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 25, 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 
coded with code 81479. In addition, the appropriate 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 June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 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 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 
billed 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 May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral formula provided on April 3, 2020. 
 
You asked the Plan to pay for the enteral formula. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the enteral formula provided on April 3, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is clinically indicated when highly conformal 
dose planning is required. 
 
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 radiation therapy. Our reviewer says 
that the services are medically necessary. Our physician reviewer found treatment with more fractions is 
costlier, which is the root of the dispute. However, 43 fractions in considered acceptable (albeit not preferable) 
by NCCN guidelines and ASTRO, ASCO, and AUA Evidence-Based Guideline ? with the expert guidelines 
acknowledging some limitations in the data. As such, the standard medical necessity criteria are met as the 
treatment with 43 fractions of IMRT would be ?furnished in accordance with accepted standards of medical 
practice?. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the management and supervision of oxygen chamber therapy 
(G0277, 99183) provided on February 24, 2020 through February 25, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the management and supervision of oxygen chamber therapy. You say that the 
services provided caused you harm so you should not have to pay anything. The Plan denied your request. The 
Plan says the claims processed according to the out of network deductible and the out of network coinsurance 
rate. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible for OON services.  
 
The item or service you asked the Plan pay for the falls within the benefit category OON physician/practitioner 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible for OON physician/practitioner services. This cost sharing is a contractual obligation that had not 
been met at the time the management and supervision of oxygen chamber therapy was received on February 
24, 2020.  
 
In addition, your contract with the Plan clearly says that you must pay a 30% coinsurance for OON 
physician/practitioner services once you have met the $500 deductible. You have been asked to pay a 30% 
coinsurance for the management and supervision of oxygen chamber therapy. The management and 
supervision of oxygen chamber therapy falls within the OON physician/practitioner 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 pay for the management and supervision of oxygen chamber therapy (G0277, 99183) 
provided on February 24, 2020 through February 25, 2020 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple power options for a power wheelchair (E2377, 
E2313, E2311). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's strength and function are adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have 2/5 upper extremity strength with independence in eating which would indicate that 
you would be able to control any power options through their own individual switches. 
 
 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve multiple power options for a power wheelchair (E2377, E2313, E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist x-rays (73110) provided on June 6, 2020. 
 
You asked the Plan to pay for wrist x-rays. You say that this procedure was performed three times on this date. 
The Plan denied your request. The Plan says this was not billed with the necessary modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that billing of modifier 76 (repeat procedure or service by the same physician or other qualified 
health care professional) or 77 (repeat procedure or service by another physician or other qualified health care 
professional) should be used to report the performance of multiple diagnostic services on the same day if these 
were not actually duplicate claims. 
 
We find that CPT code 73110 is not supported in the medical record. Specifically, this procedure was 
previously billed and paid on this date of service; therefore, it requires a modifier to indicate that it is a repeat 
procedure. Based on this information, we decided that Medicare rules for coverage of wrist x-rays have not 
been met. Therefore, we decided that the Plan does not have to pay for wrist x-rays (73110) provided on June 
6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation (99203) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion consultation 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 
a second opinion consultation (99203) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says ongoing therapy can be provided at a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
back pain associated with an L1 compression fracture sustained in a fall about one week earlier. You had 
kyphoplasty with improvement in pain. Medical problems are stable. There are no identified problems that 
need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 17, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home infusions provided. 
 
You asked the Plan to waive the coinsurance for home infusions. You say that you paid in the past and received 
another bill and disagree with the additional charges. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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% 
coinsurance for Medicare prescription drugs.  
 
You received home infusions. The total allowed amount is 
$564 and 20% of that is $112.80.  
 
You have been asked to pay the total coinsurance amount of $112.80 for home infusions. Home infusions fall 
within the Medicare 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 waive the coinsurance 
for home infusions provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were not aware that 
you would have this copayment. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
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 $35 
copayment for physician/practitioner services/in-network/specialist's office.  
 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services/in-network/specialist's office 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 a specialist office visit provided by a participating provider.