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

 
We decided that the Plan does not have to waive the coinsurance for a total hip arthroplasty procedure 
performed on December 23, 2021. We also decided that the Plan does not have to waive the copayments for 
physical therapy (PT) and occupational therapy (OT) services provided on December 24, 2021. 
 
You asked the Plan to waive the coinsurance and copayments for the hip arthroplasty and PT/OT services. You 
say that you only paid $395 for your previous procedure. The Plan denied your request. The Plan says the 
correct coinsurance and copayments were 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 per visit for outpatient surgery. 
 
Your contract with the Plan also clearly says that you must pay a $40 copayment for each therapy visit. 
 
You have been asked to pay $2,635.77, which is 20% of the allowed amount for the hip arthroplasty 
($13,178.86 allowed amount x 20% coinsurance = $2,635.77). The hip arthroplasty falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. You have also been asked to pay $22.86 for the PT services and $17.41 for the OT services. These 
amounts are both less than the $40 copayment for therapy services. The PT/OT services fall 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 a 
total hip arthroplasty procedure performed on December 23, 2021. We also decided that the Plan does not have 
to waive the copayments for physical therapy (PT) and occupational therapy (OT) services provided on 
December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on 
December 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the facility requested this provider 
to be called in to see the patient as an attending provider in an outpatient capacity. You also say there is a 
medical necessity pre-established with the patient and the facility for the providers to provide services to the 
patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. 
 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 a domiciliary or rest home visit (99337) provided 
on December 9, 2021, by an out-of-network (OON) provider.
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 requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. 
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 AVAPS 
capability. 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
   
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography of unilateral extremity (75710) and an 
angiography of each additional vessel (75774) provided on July 13, 2021. 
 You asked the Plan to pay for an angiography of unilateral extremity and an angiography of each additional 
vessel. You say that you have provided records to substantiate the services provided. 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, we have confirmed that codes 75710 and 75774 are a column II code to column I code 37228; 
however, 75710 and 75774 were billed with a modifier. 
 
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 an angiography of unilateral extremity and an angiography of 
each additional vessel. Our reviewer says that the services at issue do not meet criteria for reimbursement. Our 
reviewer found that the procedural report does not support the services at issue as distinct services from the 
revascularization procedure and therefore these services would be inclusive to CPT code 37228. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiography of unilateral extremity and an angiography of each additional 
vessel have not been met. Therefore, we decided that the Plan does not have to pay for an angiography of 
unilateral extremity (75710) and an angiography of each additional vessel (75774) provided on July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 15, 2021, 
to March 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission and inpatient hospital 
stay was medically necessary. The Plan denied your request. The Plan says based on the records, the stay that 
was provided could have been an observation stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was hemodynamically stable and did not require emergent surgery. Our 
doctor found that workup and treatment could have been completed 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on March 15, 2021, to March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says 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 the ventilator. Our reviewer says that 
the requested ventilator is not medically necessary. Our physician reviewer found the patient has diagnoses of 
obstructive sleep apnea and scoliosis. There is no diagnosis of Chronic Obstructive Pulmonary Disease, 
neuromuscular disease, or thoracic restrictive disease. Although scoliosis can cause thoracic restrictive disease, 
there is no indication from the medical record that this patient's scoliosis is that severe, and there are no 
pulmonary function tests confirming severe restriction. It is not clear from the medical record why the patient is on the ventilator. CPAP would be the appropriate treatment 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on August 30, 2021. 
 
You asked the Plan to pay for code 99053. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the medical services (99053) provided on August 30, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 based on the documentation provided 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 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 the services are not covered as billed. 
 
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 laboratory 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 the laboratory services provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 26, 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 the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on February 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that the 
requested services are medically necessary. The Plan denied your request. The Plan says services must be 
provided by 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 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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only (93010) provided on June 28, 2021. 
 
You asked the Plan to pay for code 93010. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were insufficient medical records provided for 
review to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to 
pay for the Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010) 
provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing determines the optimal treatment 
pathway for the enrollee. The Plan denied your request. The Plan says the enrollee already had a treatment 
plan. 
 
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 looked at the file and the rules. The rules say that the testing at issue is billed with code 81479. The records 
show that the testing at issue was billed with CPT code 81455. The records do not show that tissue-based 
comprehensive genomic profile testing was infeasible. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on August 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization (37228 and 37232) and moderate 
sedation services (99152 and 99153) provided on June 2, 2021. 
 
  You asked the Plan to pay for the revascularization (37228 and 37232) and moderate sedation services (99152 
and 99153). You say that to correct the left superficial femoral artery without correcting the diseased single 
vessel outflow would not have optimized the blood flow to her foot. You say that revascularization was 
successful, and compensation should be approved. The Plan denied your request. The Plan says CPT codes 
37228, 37232 and 99152 are not supported by the medical records submitted. The Plan also says CPT code 
99153 is not separately payable when performed by a physician in a facility setting.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that inpatient hospital 
services are paid under the Inpatient Prospective Payment System (PPS). All items and non-physician services 
furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements. 
 
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 revascularization (37228 and 37232) and moderate 
sedation services (99152 and 99153). Our reviewer says that the documentation submitted was reviewed and 
does not meet the criteria for coverage. Our reviewer found that the operative report describes a stent placement 
was performed and an angioplasty was performed in a sequential fashion. Therefore, CPT codes 37228 and 
37232 cannot be verified. The procedure report does not include documentation of the presence of a trained 
observer per CPT code 99152 description. 
 
In addition, Medicare criteria for coverage of the moderate sedation services (99153) have not been met. 
Specifically, CPT code 99153 is a TC only code and the claim indicates that this service was rendered in a 
facility setting. Payment for CPT code 99153 is made to the facility and is the responsibility of the facility to 
any physician or vendor.  
 
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 revascularization (37228 and 37232) and moderate sedation services (99152 
and 99153) have not been met. Therefore, we decided that the Plan does not have to pay for the 
revascularization (37228 and 37232) and moderate sedation services (99152 and 99153) provided on June 2, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.