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

 
We decided that the Plan does not have to pay for procedure codes 36215 and 75827 billed for date of service 
October 26, 2021. 
 
You asked the Plan to pay for codes 36215 and 75827. You say that the medical records support payment for 
these codes. The Plan denied your request. The Plan says codes 36215 and 75827 are not supported in the 
medical record. 
 
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 36215 is Selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. The definition of code 75827 is 
Venography, caval, superior, with serialography, radiological supervision and interpretation. 
 
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 codes 36215 and 75827. Our reviewer says that codes 36215 
and 75827 are not supported in the medical record. Our reviewer found for code 36215, the operative report 
does not include documentation of selective catheter placement, arterial system; thoracic or brachicephalic branch, first order. For code 75827, the operative report does not describe a superior caval 
venography.  Operative report documents "The subclavian vein is occluded and multiple collaterals are seen 
providing outflow from the subclavian vein distal to the occluded segment. The innominate vein and the SVC 
were not initially visualized. A second puncture was made in the access in antegrade direction from the arterial 
end, also using ultrasound guidance and micropuncture technique".  Documentation does not support 
radiographic visualization of the superior vena caval system.  Therefore, this procedure cannot be verified as 
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 codes 36215 and 75827 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 36215 and 75827 billed for date of service October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on November 10, 2021. 
 
You asked the Plan to pay for the podiatry services. You say that you were told a referral was not needed to see 
the in-network doctor and the office was not aware either. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the podiatry services provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies billed for date 
of service January 2, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that these supplies were medically necessary and 
should be paid. The Plan denied your request. The Plan says the face-to-face encounter with the patient's 
physician did not occur within the correct time frame.  The Plan also says that you billed the incorrect date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for CGMs and related supplies to be 
covered, within six months of ordering the CGM, the treating provider must have an in-person visit with the 
patient.  In addition, the rules say that the provider must use either the date of shipping or the date of delivery as the date of service on the claim. 
 
In this case, the in-person visit occurred on Apri 14, 2021, nearly nine months prior to the date of service on the 
claim.  This visit must be within six months.  In addition, you billed with date of service January 2, 2022.  
However, the records show that the date of shipment was on December 30, 2021, and the date of delivery was 
January 4, 2022.  You did not bill either of these dates as the date of service on the claim as is required. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous glucose monitor (CGM) supplies billed for date of service January 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service October 25, 
2021. 
 
You asked the Plan to pay for procedure code 99152. You say that You did not provide a specific argument 
with your appeal. The Plan denied your request. The Plan says procedure code 99152 is not supported in the 
medical record. 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, the billed 
service 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 99152 is Moderate sedation services provided by the 
same 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 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 procedure code 99152. Our reviewer says that code 99152 is 
not supported in the medical record. Our reviewer found the operative report does not include documentation of 
an independent trained observer to assist in monitoring patients level of consciousness and physiological 
status.  Operative report documents "Versed 1 mg and fentanyl 25g given for conscious sedation. Lidocaine 1 
% is for local anesthesia". The documentation does not support (per CPT code description) "requiring the 
presence of an independent trained observer".  This procedure code cannot be verified in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99152 billed for date of service October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 17, 2021, billed with 
codes 81406, 81405, 81404 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this genetic panel was not billed 
in accordance with Medicare guidelines. 
 
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 17, 2021, billed with codes 81406, 81405, 81404 and 81408.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says this item is statutorily non-covered by the Plan. 
 
The Plan must follow Medicare rules. The rules state that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on this 
information, we decided that Medicare rules for coverage of a power seat elevation feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because the LTACH is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility.  
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review has determined that you 
do have chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation in 
the medical record does not support that the ventilator at issue is medically necessary and reasonable for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on August 3, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that you process all your claims based on 
Medicare guidelines, so this claim should be paid. The Plan denied your request. The Plan says you did not file 
your claim in a timely manner. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical supplies was not filed until March 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical supplies provided on August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation and associated transport 
services (A0435, A0430, A0427, A0425) to return the enrollee to the United States for care on January 13, 
2022. 
You asked the Plan to pay for transportation back to the United States for medical care. You say that the 
enrollee required emergency medical care while on a cruise, and it was medically necessary for the enrollee to 
be transported back to the United States for a higher level of care. The Plan denied your request. The Plan says 
the requested air ambulance transportation was not medically necessary and did not meet Medicare criteria for 
coverage. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate. The rules say also that 
emergency transportation is covered when it is provided from any point of origin to the nearest hospital or 
skilled nursing facility capable of furnishing appropriate care for a patients illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency transportation have not been met. Specifically, there were multiple 
other countries which were closer to the enrollee at the time of the emergency which may have had the ability 
to provide adequate treatment. In addition, even if transportation to the United States was necessary due to a 
lack of available treatment, it was not necessary to transport the enrollee to their home state when there were 
several coastal states which would have required less travel. Therefore, we decided that the Plan does not have 
to pay for air ambulance transportation and associated transport services (A0435, A0430, A0427, A0425) to 
return the enrollee to the United States for care on January 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing/monitoring services (95861, 95940, 
95938) provided on December 14, 2021. 
 
You asked the Plan to pay for diagnostic testing/monitoring. You say that these services are provided 
independently because the facility cannot provide them. The facility cannot bill for services they did not 
provide, so the health plan should pay. The Plan denied your request. The Plan says the payment for these 
services is bundled into the facility payment. The provider should bill the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. The services at issue were provided to an inpatient enrollee and 
include the technical component of services. These services are therefore included in the payment to the 
facility, and separate payment may not be made. Based on this information, we decided that Medicare rules for 
coverage of diagnostic testing/monitoring have not been met. Therefore, we decided that the Plan does not have 
to pay for diagnostic testing/monitoring services (95861, 95940, 95938) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing is supported in the medical record. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor. 
 
You asked the Plan to pre-approve the requested services The Plan denied your request. The Plan says you do 
not have a need for more clinical data beyond what was already obtained. 
 
The Plan follows Medicare rules. Medicare rules say that outpatient cardiac telemetry is 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 you have a history of bradycardia and sick sinus syndrome, for which a pacemaker is 
planned. As such, guidelines would not support a need for MCOT monitoring in this setting. In summary, there 
is insufficient documentation to support the medical necessity for an MCOT monitor for clinical management. 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 mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you are in constant pain. The Plan denied your request. 
The Plan says you have not tried and failed one of the preferred drugs. 
 
 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 Botox. Our physician reviewer found 
that you have spasmodic torticollis. The Plan requires a trial of Dysport or Xeomin before they will approve the 
requested drug. In this case, you have not tried and failed the required drugs. There is no documentation 
provided indicating that the Plans required drugs would likely be less effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease and was recently 
admitted with hypercarbia. The record indicates that the enrollee was successfully treated with bilevel positive 
airway pressure (BiPAP) and had a significant reduction in carbon dioxide (C02) after only 45 minutes of 
treatment. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular genetic testing provided 
on February 24, 2022, billed with codes 81286, 81413, 81414, 81442, 81661 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says these services were billed in a way which 
misrepresents the care provided. 
 
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 comprehensive cardiovascular genetic testing provided on February 24, 2022, billed with codes 81286, 81413, 81414, 81442, 
81661 and 81479.