Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97530) provided September 2, 2021 
to September 16, 2021. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 97110, & 97530 are not supported in the medical record. Specifically, the services 
were performed in the home by a therapy assistant. There is a more appropriate code to describe this service 
(G0157, G0158). Based on this information, we decided that Medicare rules for coverage of the therapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services 
(97110, 97530) provided September 2, 2021 to September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided November 4, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 99233 is not supported in the medical record. Specifically, surgical codes 36556 and 
31500 were billed on the same date of service. The physician services are within the global surgery period of 
the surgical services billed. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99233) provided November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 9, 
2021. 
 
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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 29885 is "Surgical knee arthroscopy with drilling for 
osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base 
of lesion)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records do not support that CPT 
29885- surgical knee arthroscopy with drilling for osteochondritis dissecans with bone grafting, with or without 
internal fixation (including debridement of base of lesion) was actually rendered in this case. The operative procedure dated 9/9/21 documented that under fluoroscopic guidance, a subchondroplasty was performed, 
drilling a small insertion needle into the proximal tibia under fluoroscopic guidance and through this, four 
syringes of calcified material was injected into the medial plateau, and filled the subchondral area nicely. As 
the injectate was four syringes of calcified material; the CPT 29885 is not supported by the records. The CPT 
code 29885 specifically states that holes are drilled into the lesion, and bone is harvested from the patients hip, 
rib, or skull for grafting. The procedure noted dated 9/9/21 corroborated the grafting was calcified material and 
not harvested bone. Therefore, the records do not support the coding of CPT 29885. 
 
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 surgical services provided to the enrollee on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (procedure code 95885) provided 
to the enrollee on April 22, 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 denied code is not supported by the medical records submitted. 
 
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 95885 is "Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, a claim was 
submitted for CPT code 95885. The records provided for review however did not support that this service had 
been rendered as billed. Notably, there is no indication in the claim or the information provided that a nerve conduction study (NCS) was done as part of the evaluation of this patient. More specifically, NCS is generally 
not done as part of intraoperative neuromonitoring. As such the CPT code under review cannot be said to have 
been supported by the records. 
 
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 needle electromyography (procedure code 95885) provided to the enrollee on April 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on September 
17, 2021. 
 
You asked the Plan to pay for the subsequent hospital care (99232). You say that the patient was not enrolled in 
Medicare from September 6, 2021, through September 24, 2021 and the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for [laboratory services provided to the enrollee on September 
29, 2021. 
 
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 ESRD-related laboratory services cannot be reported separately. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
[laboratory services provided to the enrollee on September 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual mental health services (90791) provided on 
November 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the virtual mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this service is only covered when obtained 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 virtual mental health services (90791) provided on November 13, 2021 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response without transport provided on 
September 29. 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you were not aware that this would only 
be covered if you were transported to this hospital. You do not feel that this makes sense as being sent to the 
hospital and exposing yourself to COVID-19 would be more expensive to the Plan. The Plan denied your 
request. The Plan says Medicare only covers ambulance services when transportation has occurred. Ambulance 
services without transportation are noncovered. 
 
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 September 29, 2021. 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 response without transport 
provided on September 29. 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0998) provided November 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there was no transport and this service is not eligible for payment. 
 
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 November 30, 2021. 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 ambulance services (A0998) provided November 
30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two second level injections (64494) provided on November 
16, 2021. 
 You asked the Plan to pay for two second level injections. You say that the records support two units of this 
service. The Plan denied your request. The Plan says the billed units exceed MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of two 
second level injections have not been met. Therefore, we decided that the Plan does not have to pay for two 
second level injections (64494) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight psychotropic test (81479) provided June 28, 2021. 
 
You asked the Plan to pay for GeneSight psychotropic test. You say that you request reconsideration of the 
original determination and cover the GeneSight psychotropic test as medically necessary. The Plan denied your 
request. The Plan says the service does not meet the Medicare criteria. 
 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 pay for GeneSight psychotropic test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the case file contains a GeneSight Order Medical Necessity Documentation form, and 
the results of the GeneSight testing. The case file does not contain additional clinical information for review. 
This testing does not meet the Medicare criteria for payment. The documentation is insufficient to support that 
the GeneSight genetic testing was medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneSight psychotropic test have not been met. Therefore, we decided that the 
Plan does not have to pay for GeneSight psychotropic test (81479) provided June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found as a practical matter, the enrollee does not 
require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services provided to the enrollee on 
October 26, 2021. 
 
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 provider must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations, and the date of consultations in the 
patients medical record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy services provided to the 
enrollee on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D biopsy provided to the enrollee on August 27, 
2021. 
 
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 a review of the medical literature and clinical practice guidelines does not support the clinical 
utility of this testing, including computer-assisted immunohistochemistry, to predict cancer. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined  that the requested WATS3D biopsy does not meet Medicare rules because a 
review of the medical literature and clinical practice guidelines does not support the clinical utility of this testing, including computer-assisted immunohistochemistry, to predict cancer. The requested services at issue 
in this case are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D biopsy provided to the enrollee on August 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sacituzumab govitecan-hziy. 
 
You asked the Plan to pre-approve Sacituzumab govitecan-hziy. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Sacituzumab govitecan-hziy. Our 
reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee does 
not have triple negative breast cancer. The medication is not medically reasonable and necessary or safe and 
effective 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 Sacituzumab govitecan-hziy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Sacituzumab govitecan-hziy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope. 
 
You asked the Plan to pre-approve microsurgical techniques, requiring use of operating microscope. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 microsurgical techniques, requiring use 
of operating microscope. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the microscope is included in the code for 
the surgery. It cannot be unbundled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microsurgical techniques, requiring use of operating microscope have not been 
met. Therefore, we decided that the Plan does not have to pre-approve microsurgical techniques, requiring use 
of operating microscope.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341) provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the services were not emergent. There were network providers available. 
 
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 service 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 lab services (88341) provided on July 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee from October 
17, 2021, to October 18, 2021. 
 
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 claim is lacking information. 
 
The Plan must follow Medicare rules. Medicare rules 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of critical care services provided to the 
enrollee from October 17, 2021, to October 18, 2021. have been met. The provider has not sent in a claim that has a valid NPI or tax ID. Payment cannot be made without this information. Therefore, we decided that the 
Plan does not have to pay for critical care services provided to the enrollee from October 17, 2021, to October 
18, 2021.