Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232-GC) provided on 
February 10, 2022. 
 
You asked the Plan to pay for code 99232-GC. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The subsequent hospital care in question was provided within the 90-
day global period for the surgical procedure (code 44120) that was provided on February 11, 2022. This means 
that payment for the subsequent hospital care was included in the payment for the surgical procedure. Based on 
this information, we decided that Medicare rules for coverage of code 99232-GC have not been met. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99232-GC) provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a technetium contrast agent, regadenoson 
injection, and saline infusion provided on October 25, 2021. 
 
You asked the Plan to waive the coinsurance for the contrast agent, injection, and infusion. You say that you 
were not aware of the coinsurance for the supplies. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 for medical supplies, such as chemical agents used in certain diagnostic procedures. 
 
Your contract with the Plan also clearly says that you must pay a 5% coinsurance for each Part B drug. 
 
Item/Drug Allowed Amount Coinsurance 
Technetium Contrast $708.00 $141.60 (20%) 
Regadenoson $238.20 $11.91 (5%) 
Saline Infusion $0.72 $0.04 
Total:  $153.55 
 
You have been asked to pay $153.55 for the contrast agent, injection, and infusion. The contrast agent falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The injection 
and infusion fall within the Medicare Part B Prescription Drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a technetium contrast agent, regadenoson injection, and saline infusion provided 
on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by an 
out-of-network provider on July 13, 2021. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you needed to see if you had an 
infection in your mouth before you had heart valve surgery. The Plan denied your request. The Plan says 
D0330 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330) provided by an out-of-network provider on July 13, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on October 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on October 18, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on December 20, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the special 
anesthesia service rendered on December 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 12, 2021 
to September 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of 
three Q codes. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with one of the 
required Q codes. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from September 12, 2021 to September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing of autonomic nervous system function (95921, 
95923) provided on December 1, 2021. 
 
You asked the Plan to pay for testing of autonomic nervous system function. You say that you have provided 
records to support the services billed. The Plan denied your request. The Plan says rules for payment have not 
been met because the available 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 95921 is "Testing of autonomic nervous system function; 
cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to 
deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio"; and the definition of code 95923 is 
"Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative 
sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in 
sympathetic skin potential." 
 
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 testing of autonomic nervous system function. Our reviewer 
says that the services at issue do not meet criteria for reimbursement. Our reviewer found that the available 
documentation does not describe evaluation of function of the autonomic nervous system, which controls body 
functions, such as heart rate, temperature regulation, and other functions that are involuntary; nor does the 
available documentation describe testing of the autonomic nervous system to check functioning of nerves that 
supply sweat glands. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing of autonomic nervous system function have not been met. Therefore, we 
decided that the Plan does not have to pay for testing of autonomic nervous system function (95921, 95923) 
provided on December 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270), and transcutaneous 
electrical joint stimulation device (TEJSD) (E0762) provided in an outpatient setting from August 30, 2021, to 
September 27, 2021. 
 
You asked the Plan to pay for the self-administered drugs and TEJSD. You say that you have received 
reimbursement for these services in the past. The Plan denied your request. The Plan says the claim processed 
correctly. 
 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 TEJSD. Our reviewer says that the 
requested TEJSD is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that service in question was performed at an office setting. 
Therefore, the reviewer found that the TEJSD was processed correctly according to the enrollee's plan. 
 
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 self-administered drugs and TEJSD have not been met. Therefore, we 
decided that the Plan does not have to pay for the self-administered drugs (A9270), and transcutaneous 
electrical joint stimulation device (TEJSD) (E0762) provided in an outpatient setting from August 30, 2021, to 
September 27, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has 
been approved for CT of the chest and it is reasonable to do a CT surveillance of the abdomen and pelvis at the 
same sitting. The reason is that the presence of pulmonary metastases indicates a hematologic spread of cancer 
thus making the enrollee at risk for abdominal disease as well, particularly the liver. Thus, a surveillance CT of 
the abdomen and pelvis conducted during the already approved CT of the chest is reasonable. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. 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. 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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found nonetheless, there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in enrollee's management. As a result, at 
this time the CardioMEMS system would not be considered medically appropriate and necessary in this 
enrollees 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation provided by a participating provider on 
December 3, 2021. 
 
You asked the Plan to pay for a consultation. You say that you never had an x-ray provided. The Plan denied 
your request. The Plan says the services provided are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation provided by a participating provider 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 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 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system (L5781). 
 
You asked the Plan to pre-approve a vacuum socket system. You say that this device is medically necessary for 
the enrollee. The Plan denied your request. The Plan says there are not enough medical studies to show the 
vacuum socket system is better than a standard socket for a prosthetic leg. 
 
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 vacuum socket system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested prosthetic accessory exceeds the patient's medical needs and is not 
proven superior to a standard socket. Per documentation the appeal letter indicates a recommendation for an 
elevated vacuum system. The literature reviewed indicates that further research is needed with clinical trials that recruit larger sample sizes and report long-term outcome data for the requested vacuum suspension system. 
 
 
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 vacuum socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum socket system (L5781).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zepzelca. 
 
You asked the Plan to pre-approve Zepzelca. 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 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 Zepzelca. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found lubrenectedin is not approvable as 
subsequent therapy for a large cell neuroendocrine carcinoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zepzelca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Zepzelca.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Magnetic resonance (eg, proton) imaging (MRI) (73718) 
provided on December 30, 2021. 
 
You asked the Plan to pay for code 73718. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the Magnetic resonance (eg, proton) imaging (MRI) (73718) 
provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve heart surgery. You say that you do not want to provide this service at a 
hospital facility due to high risk of COVID. The Plan denied your request. The Plan says the services have been 
requested from an out-of-network provider. The requested heart surgery is available in-network at surgical 
centers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
heart surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for homocysteine (83090) and fibrin degradation products, D-
dimer; quantitative (85379) provided June 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee had already established care 
with the doctor and wishes to continue seeking services for this condition under this physician at this location. 
The Plan denied your request. The Plan says exact duplicate claim/service. 
 
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 find that CPT code 83090 and 85379 is not supported in the medical record. Specifically, CPT 
code 83090 was already billed on another claim and was processed and paid on 07/02/2021. CPT code 85379 
was already billed on another claim and was processed and paid on 6/30/2021. The documentation received 
also does not include medical records for codes 83090 and 85379 performed. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for homocysteine (83090) and fibrin degradation products, D-dimer; 
quantitative (85379) provided June 21, 2021.