Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 28, 2019. 
 
You asked the Plan to pay for Protein; electrophoretic fractionation and quantitation, serum (84165) and 
Immunofixation electrophoresis; serum (86334). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says that the testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Protein; electrophoretic fractionation and 
quantitation, serum (84165) and Immunofixation electrophoresis; serum (86334). Our reviewer says that the 
services were considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee was undergoing screening for contraindications for liver transplant which includes protein and 
immunofixation electrophoresis testing, which was appropriate and medically necessary based on the provided 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Protein; electrophoretic fractionation and quantitation, serum (84165) and 
Immunofixation electrophoresis; serum (86334) have been met. Therefore, we decided that the Plan has to pay 
for the laboratory services provided on November 28, 2019.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(HCPCS G0453) provided to the enrollee on May 13, 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 Healthcare Common Procedure Coding System (HCPCS) code G0453 (19 Units) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of HCPCS code G0453 is "continuous intraoperative 
neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention 
directed exclusively to one patient) each15 minutes." 
 
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 this code 
requires monitoring to be performed remote or near by operating room, attention directed exclusively to one 
patient and a timed reported code.  Documentation does not support these requirements needed to confirm 
HCPC G0453 was performed. 
 
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 continuous intraoperative neurophysiology monitoring (HCPCS G0453) provided to the 
enrollee on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has chronic heart failure 
with multiple hospitalizations. The Plan denied your request. The Plan says the service is not widely used and 
generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of hypertension, lymphoma, colon cancer, sleep apnea, diabetes, 
hyperlipidemia, coronary artery disease and NYHA Class III congestive heart failure, requiring hospital 
admission. In this circumstance, therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. The 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure. Therefore, the device is considered 
experimental and investigational. 
 
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 CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance services coded P9604 provided on 
August 20, 2019. 
 
You asked the Plan to pay for the travel allowance 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 P9604 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. Specifically, the documentation 
submitted did not include documentation of travel allowance, one way in connection with medically necessary 
laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge; 
therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the travel allowance services have not been met. Therefore, we decided that the Plan does not have 
to pay for the travel allowance services coded P9604 provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refractive eye exam (92015) performed on May 28, 2020. 
 
You asked the Plan to pay for a refractive eye exam. You say that no one told you that the service in question 
was not covered under the Plan at your provider's office. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a Vision Care Provider. 
 
We looked at the file and the Plan's rules. The case record reflects that your provider is not a valid provider for 
this service. Based on this information, we decided that the Plan's rules for coverage of a refractive eye exam 
have not been met. Therefore, we decided that the Plan does not have to pay for a refractive eye exam (92015) 
performed on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hyaluronan injection provided by on 
June 3, 2020. 
 
You asked the Plan to waive the coinsurance for the hyaluronan injection. You say that you are asking for the 
$113.76 that you paid for the injection back. The Plan denied your request. The Plan says the coinsurance 
applied 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 20% 
coinsurance for chemotherapy and other drugs covered by Medicare Part B. 
 
You have been asked to pay $269.54, which is 20% of the allowed amount for the hyaluronan injection. The 
allowed amount is $1,347.69 (20% x $1,347.69 = $269.54). The hyaluronan injection falls 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 waive the coinsurance for 
the hyaluronan injection provided by on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain full function and 
mobility. The Plan denied your request. The Plan says the enrollee does not need the care of a rehab doctor, or 
an intensive rehab team. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for surgical treatment of a hip fracture. Her medical 
problems are stable. 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 medical record 
supports a need for physical and occupational therapy, but it does not support a need for an intensive 
rehabilitation therapy program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on July 13, 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 billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that inpatient services must be billed with POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue. The claim was incorrectly billed with POS code 22. 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 chest x-ray rendered on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9123) provided from July 5, 2020, to July 11, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S9123 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 the 
services (S9123) provided from July 5, 2020, to July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided on December 13, 2019, through 
December 24, 2019. 
 
You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim does not include the 
required G code. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that the claim must include a GN, GO or GP modifier 
to distinguish the discipline of the plan of care under which the service is delivered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Specifically, the claim has been billed with therapy codes 
that do not include the required GN, GO or GP modifier. Therefore, we decided that the Plan does not have to 
pay for therapy services provided on December 13, 2019, through December 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
orders 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 22, 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 
22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography with 
contrast administration, including post-processing of parametric maps with determination of cerebral blood 
flow, cerebral blood volume, and mean transit time (CPT Code 0042T) provided on November 28, 2019. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says cerebral perfusion analysis is considered not reasonable and necessary by Medicare and is 
excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Cerebral perfusion analysis is considered not reasonable and 
necessary by Medicare and is excluded from coverage.  
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis using computed 
tomography with contrast administration, including post-processing of parametric maps with determination of 
cerebral blood flow, cerebral blood volume, and mean transit time (CPT Code 0042T) provided on November 
28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bone density measurement of the core 
or central skeleton and screening mammography of both breasts (77080, 77067) provided on February 19, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for the bone density measurement of the core or central skeleton 
and screening mammography of both breasts. You say that you were under the impression these were covered 
services. The Plan denied your request. The Plan says the coinsurance applied correctly in this case. 
 
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 40% 
coinsurance for OON covered screening mammograms and a 40% coinsurance for OON Medicare-covered 
radiological diagnostic services. 
 
You have been asked to pay a total cost share amount of $75.64 for the bone density measurement of the core 
or central skeleton and screening mammography of both breasts ($16.90 + $58.74). The services provided fall 
within the OON screening mammogram and ON radiological diagnostic services 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 bone density measurement of the core or central skeleton and 
screening mammography of both breasts (77080, 77067) provided on February 19, 2020, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 3, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on July 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on January 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you must receive 
services from network providers. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on 
January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (93308) provided on June 
26, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your provider medically necessary 
services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking 
reimbursement from your office. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 subsequent nursing facility care (93308) provided on June 26, 2019 by an out 
of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye examination provided on June 5, 2020. 
 
You asked the Plan to pay for the routine eye examination. You say that the services provided were necessary. 
The Plan denied your request. The Plan says Medicare does not cover routine eye examinations (sometimes 
called "eye refractions"). 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you have received cataract surgery. 
 
 
 
 
 
 
We looked at the file and the Plan's rules. From the file, we decided that you are not receiving a routine eye 
examination following cataract surgery. Based on this information, we decided that the Plan's rules for 
coverage of the routine eye examination have not been met. Therefore, we decided that the Plan does not have 
to pay for the routine eye examination provided on June 5, 2020.