Persius/hicric huggingface dataset:
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 March 9, 
2022. 
 
You asked the Plan to pay for procedure code 99152. You say that the medical records support payment for this 
code. The Plan denied your request. The Plan says code 99152 is not supported in the medical record. The 
submitted medical records do not include sufficient detail to support that moderate sedation services occurred. 
All other billed codes have been paid. 
 
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 patients level of consciousness and physiological status; initial 15 minutes of intra-service 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 procedure 
code 99152 is not supported in the medical record. Our reviewer found the medical records provided from date 
of service March 9, 2022, do not show that moderate sedation services were provided. 
 
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 March 9, 2022.
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 requested SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for SNF care have 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that, based on the limited documentation provided, you do not qualify for SNF 
care. You do not have documented skilled nursing needs. You do does not have documented skilled therapy 
needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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 SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 26, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says there was 
no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. The file shows that there was no documented contact with the 
attending/primary care physician. Based on this information, we decided that Medicare rules for coverage of 
psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided on April 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance angiography (MRA) of the brain 
 
You asked the Plan to pre-approve an MRA of the brain. You say that you feel this service should be covered 
because you are having severe headaches, extreme pain, and are unable to turn your neck. The Plan denied your 
request. The Plan says that there is no documentation saying your issues have gotten worse since the magnetic 
resonance imaging that was provided on August 18,2022. The Plan also says that medical necessity is not 
established as the criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that all of the criteria listed in the Medicare rules section 
of this letter must apply in order for Medicare to provide coverage for an MRA of the head and neck. 
 
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 an MRA of the brain. Our reviewer 
says that an MRA of the brain is reasonable and necessary. Our physician reviewer found you have a history of 
severe headaches, increasing in severity. Importantly, you have a family history of intracranial aneurysm, 
which may be an inherited disorder. Our reviewer fount that your prior magnetic resonance imaging (MRI) was 
negative. Our physician reviewer also found that the requested MRA is necessary to evaluate for intracranial 
aneurysm, which is an appropriate test given your clinical history and family history. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance angiography (MRA) of the brain  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an MRI provided on March 28, 2022. 
 
You asked the Plan to waive the coinsurance for an MRI. You say that you should not be responsible to pay 
this. The Plan denied your request. The Plan says the cost share was 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 a 20% 
coinsurance up to $75 per day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $75 for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
Magnetic Resonance Imaging (MRI) provided on March 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. The Plan denied your request. The Plan says 
the policy criteria are not met, and medical necessity is not established. 
 
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 a wireless capsule endoscopy. Our 
reviewer says that the requested wireless capsule endoscopy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the record indicates that the enrollee has a history of 
gastrointestinal bleeding. A colonoscopy has demonstrated diverticulosis and an upper endoscopy has 
identified a duodenal arteriovenous malformation, believed to be the bleeding source. Our reviewer found that 
the known bleeding source has not been treated. Our physician reviewer also found the record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
authorization for long-term acute care hospital admission. The Plan denied your request. The Plan says 
admission to LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered, until you could discharge to a lower level of care. 
 
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 you appear to be stable and improving and should only require short term additional 
acute care hospital services that can safely be administered at the current facility until more appropriate for a 
lower level of care. You do 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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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, for 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 March 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided January 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the F1Heme test is a proven medically necessary 
covered benefit for comprehensive genomic profile testing for cancer to identify potential targeted therapy 
options. The Plan denied your request. The Plan says that Genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as 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 the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow or peripheral blood cells should be assayed for Myelodysplastic syndromes 
(MDS)-associated gene mutations using gene panels that include genes listed on MDS-C. These gene mutations 
can establish the presence of clonal hematopoiesis, which can help exclude benign causes of cytopenias in 
cases with non-diagnostic morphology, but do not establish a diagnosis of MDS in the absence of clinical diagnostic criteria (See Genes Frequently Somatically Mutated in MDS [MDS-C] and Discussion). As clonal 
hematopoiesis is a frequent consequence of aging, the finding of mutations in MDS-associated genes should be 
interpreted with caution and does not in isolation establish a diagnosis of MDS. The majority of patients with 
WHO-defined MDS have a somatic mutation detected in one of the commonly mutated MDS-associated genes. 
e A heritable hematologic malignancy predisposition syndrome may account for cytopenias with or without 
MDS in some patients. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA 
analysis, and RNA analysis when performed, 51 or greater genes (81455) provided January 21, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your inpatient stay has reached the 100-day benefit limit for this 
admission. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 24, 2022, through 
October 1, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on January 24, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit 
and there should be no copayment. The Plan denied your request. The Plan says the copayment was 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 a $10  
copayment for an office visit.  
 
You have been asked to pay $10 for an office visit. An office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. Records submitted support this was not an annual 
wellness visit. 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 on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve repair services for a power wheelchair. 
 
You asked the Plan to pre-approve repair services for a power wheelchair. You say that the requested repairs 
are a medical necessity for you. The Plan denied your request. The Plan says that rules for coverage have not 
been met because the cumulative cost of repairs exceeds the cost of replacement for the power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case record shows that the figure used by the Plan for the cost 
of replacement for the power wheelchair is based on the estimated cost of the current wheelchair provided in 
2014. This cannot be assumed to be the cost of replacement in 2022. Furthermore, you have provided at appeal 
an estimated cost for replacement considerably higher than the estimate used by the Plan. 
 
It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pre-approve repair 
services for a power wheelchair.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on October 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services. 
 
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 skilled nursing services provided on October 8, 
2021, by an out-of-network (OON) provider.
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 requested SNF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for SNF care have 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that, based on the documentation provided, you do not qualify for SNF care. You do 
not have documented skilled nursing needs. You are tolerating your current therapy regimen. You are likely at 
or near a plateau in function. 
 
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 SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy provided on April 7, 
2022. 
 
You asked the Plan to waive the coinsurance for physical therapy. You say that you should not be responsible 
to pay this. The Plan denied your request. The Plan says the cost share was 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 a 50% 
coinsurance for physical therapy provided in a specialist's office.  
 
You have been asked to pay $35.52 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation 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 physical 
therapy provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 31, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99072 is considered bundled and 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 procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 31, 2022.