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

 
We decided that the Plan does not have to pay for procedure code 49329 billed for services provided on 
December 3, 2021. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the level of care 
provided. The Plan denied your request. The Plan says the code cannot be verified. 
 
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 49329 is unlisted laparoscopy procedure, abdomen, 
peritoneum and omentum. We find that CPT code 49329 is not supported in the medical record. Neither the 
claim, nor the medical records provide details about what procedure is considered unlisted. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 49329 billed for services provided on 
December 3, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for agitation and restlessness. The enrollee's medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that Leqvio is the best choice for the enrollee. The Plan 
denied your request. The Plan says the Plan requires a trial of Praulent before it will approve Leqvio. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Leqvio. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Leqvio. Our physician reviewer 
found the record does not show that the enrollee has tried and failed the Plan's preferred drug of Praulent. The 
record does not show that this drug would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Leqvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet the guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions 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 has chronic low back pain. Magnetic resonance imaging (MRI) showed facet 
arthropathy and a disc bulge. On August 10, 2022, the enrollee underwent diagnostic medial branch blocks 
(MBBs) and achieved 100% pain relief. The request was placed for RFA of the medial branches. The coverage 
criteria require two sets of diagnostic MBBs be performed, each of which produce over 80% pain relief. Here 
only one set has been performed. Therefore, at this point, the request is not medically reasonable or 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 radiofrequency ablation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded A0429 provided on April 21, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that as an ET3 provider, this service should be 
covered. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that CPT code A0429 is not supported in the medical record. Specifically, this service was billed with 
modifier "RW." W is not listed as a valid origin/destination modifier for ambulance services. This means this 
service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services coded A0429 provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 5, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 5, 2022, billed with codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on April 27, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
There is no documentation provided to describe the purpose for the pharmacogenomic testing and/or how it 
would affect the enrollee's treatment plan. This means that the laboratory testing at issue in this appeal was 
requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient hospital surgery provided on 
June 06, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient hospital surgery. You say that you are appealing 
the copayment for outpatient surgery services because you were told it was $200. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery services. 
 
You have been asked to pay a $350 copayment for an outpatient hospital surgery. This item/service falls within 
the outpatient surgery 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 reduce the copayment for 
an outpatient hospital surgery provided on June 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on December 8, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not supported. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation did not include medical records. No progress notes were submitted to determine the clinical 
utility of the testing rendered. This means that the laboratory testing at issue in this appeal was requested solely 
for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for the laboratory testing provided on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine 
provided on July 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP machine. You say that you bought this machine because your other 
machine was recalled. You also say hat your doctor was concerned that you would get COVID-19 because of 
your respiratory condition. The Plan denied your request. The Plan says the item received is not a covered 
benefit when received by an OON provider. 
 
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 had network providers 
available who could have provided 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 continuous positive airway pressure (CPAP) 
machine provided on July 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on July 14, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the purpose of your visit was for 
your annual Medicare wellness exam. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. The Plan says you received your last wellness visit in November of 2021, which means you 
would not be eligible for another wellness visit until November of 2022. Therefore, the Plan says the cost 
sharing was applied to your physician/practitioner services benefit.  
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue 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 $10 
copayment for each Medicare-covered primary care doctor visit.  
 
You have been asked to pay a $10 copayment for an office visit. This service falls within the 
physician/practitioner services, including doctors office visits 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 an office visit (99214) provided on July 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that due to the enrollee's medical 
history, inpatient level of care is more appropriate. The Plan denied your request. The Plan says this surgery 
can be performed as outpatient with consideration for inpatient level of care given if any medical issues 
develop. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the shoulder arthroplasty is currently approved as an ambulatory procedure. 
There is no documentation to support the expectation that the enrollee will require a greater than 2-midnight 
hospital stay. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 requires daily physician management 
and intensive therapies to optimize mobility and strength. You say that the enrollee's needs cannot be safely 
met by a skilled nursing facility or home health at this time. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee can safely receive the services they need in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on June 8, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the office is requesting too much 
money for these services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for medical care or surgery services in a Specialty Physician's office.  
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the medical 
care or surgery services in a Specialty Physician'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 the office visit provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12013 billed for date of service June 20, 
2021. 
  You asked the Plan to pay for procedure code 12013. You say that these codes are appropriately identified as 
separate procedures and the claim should be processed for prompt payment. The Plan denied your request. The 
Plan says payment for code 12013 is bundled into payment for code 21310. 
 
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, we have confirmed that code 12013 
is a column II code to column I code 21310. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12013 billed for date of service June 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport provided on August 
10, 2022. 
 
You asked the Plan to waive the copayment for transportation services. You say that neither you nor the 
enrollee agreed to an ambulance ride. You say the ambulance service was refused but not honored. The Plan 
denied your request. The Plan says this cost sharing was charged correctly for the services rendered.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment for ambulance services.  
 
The enrollee has been asked to pay a $300 copayment for an ambulance transport from the assisted living 
facility to the hospital emergency department. This service falls within the ambulance services benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan.  
 
 This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for an ambulance transport provided on August 
10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for services provided on March 
17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the service was coded correctly. The Plan denied 
your request. The Plan says the claim denied correctly. 
 
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 code 69209 is removal impacted cerumen using 
irrigation/lavage, unilateral. 
 We find that CPT code 69209 is not supported. The claim does not show that code 69209 was billed with an 
anatomic modifier as required. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
69209 billed for services provided on March 17, 2022.