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

 
We decided that the Plan does not have to pay for the office visit provided on June 1, 2021. 
 
You asked the Plan to pay for the office visit. You say that there is no global period, and the claim was denied 
incorrectly. You say that the attached medical records should be reviewed, and the claim should be 
reprocessed. The Plan denied your request. The Plan says procedure code 99213 is included in the global 
surgery period of procedure code 11102 when billed without an appropriate modifier. 
 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit billed on June 1, 2021. 
have been met. The Plan paid for one office visit billed by this provider on this date. Sufficient medical records 
were not submitted to support that two office visits were provided on this date. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on September 28, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 the Guardant360 testing (81479) provided on 
September 28, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the ambulance service, basic life support, non-
emergency transport (A0428) and the ambulance mileage (A0425) provided on January 6, 2022. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the cost share has been applied correctly 
to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for non-emergency ambulance services 
rendered by an out-of-network provider.  
 
The Plan says you must pay a $51.37 cost share for the ambulance service provided. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 copayment for non-emergency ambulance 
services rendered by an out-of-network provider. Therefore, we decided that the Plan has to waive the cost 
share for the ambulance service, basic life support, non-emergency transport (A0428) and the ambulance 
mileage (A0425) provided on January 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (Q4246) provided August 31, 2021. 
 
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 8[enter the number of units] units of CPT code Q4246 are not supported in the medical record. 
The medical record only supports 2 units of CPT code Q4246. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pay for injections (Q4246) provided August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 
87634, 87640, 87798) provided September 3, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (87486, 87496, 87498, 87502, 87532, 87541, 87634, 87640, 
87798) provided September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy (CPT code 29822-59-RT) provided on 
August 11, 2021. 
 
You asked the Plan to pay for the arthroscopy. You say that the claim should be paid. The Plan denied your 
request. The Plan says this procedure is considered inclusive to CPT code 29827-RT, a surgical shoulder 
arthroscopy, with rotator cuff repair; therefore, the code 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. 
 
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 arthroscopy. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. Per Centers for Medicare & Medicaid Services (CMS), a 
limited debridement is inclusive to surgical arthroscopy shoulder procedure and would not be reported 
separately. 
 
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 arthroscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for the arthroscopy (CPT code 29822-59-RT) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopy (separate procedure), up to 1 hour physician 
or other qualified health care professional time (CPT code 76000) provided on July 21, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this code is included in CPT code 33208; therefore, it cannot be separately reimbursed. The Plan 
states the documents received do not support that the procedure or service was distinct or independent from 
other services performed; therefore, the use of the 59 modifier is not supported. 
 
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 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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. CPT 76000 would be bundled with the primary procedure performed 
at same session. CPT fluoroscopy codes 76000 (up to 1 hour physician time) and 76001 (physician time greater 
than 1 hour) are intended for use as stand-alone codes when fluoroscopy is the only imaging performed. 
Therefore, this procedure would not be covered with additional procedures. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care 
professional time (CPT code 76000) provided on July 21, 2021.
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 services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of the LTACH services. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 20, 2020. 
 
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 November 20, 2020.
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 services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of the LTACH services. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for an inpatient hospital admission associated with the laparoscopy. The Plan denied your request. The 
Plan says the enrollee does not meet any of the requirements for an inpatient 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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission have been 
met.  Our physician reviewer found there is no documentation that inpatient care to span two midnights for the 
laparoscopic hiatal hernia repair with fundoplication meets Medicare criteria for medical necessity as opposed 
to outpatient care with the option to transition to inpatient care if the enrollee's condition requires it in the post-
operative period. The provided medical records document no unstable pre-operative medical conditions which 
would require inpatient care in the hospital to span two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided to the enrollee on 
June 28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support this level of care. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity." 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, our reviewer found that all 3 
key components have not been met or exceeded. The documentation supports an expanded problem focused 
history; a comprehensive exam, and medical decision making of low complexity.  
 For history: expanded HPI, ROS extended, PFSH pertinent to problem;  Exam 10 organ systems reviewed, and 
medical decision making: problem status 4, minimal complexity reviewed and minimal management 
options. Therefore, documentation submitted support CPT 99282 level of service. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency department visit provided to the enrollee on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Introduction of needle or intracatheter in vein (36000) 
provided on April 8, 2021. 
 
You asked the Plan to pay for code 36000. 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 36000 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 Introduction of needle or intracatheter in vein (36000) provided on 
April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits (97139). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior physical therapy and the documentation 
does not reveal that the enrollee requires the ongoing unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The 
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits (97139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RomTech portable connect adaptive rehabilitation 
device and a remote treatment function device. 
 
You asked the Plan to pre-approve RomTech portable connect adaptive rehabilitation device and a remote 
treatment function device. You say that this item is needed due to a recent knee surgery. The Plan denied your 
request. The Plan says the requested DME is an exercise bicycle equipment and therefore a non-covered item 
and a non-medical item in nature. 
 
The Plan must follow Medicare rules. The rules state that a continuous passive motion device is covered only 
for enrollees who had a total knee replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RomTech portable connect adaptive rehabilitation device and a remote treatment function device 
have not been met. Specifically, the record shows that you did not have a total knee replacement. This means 
that you do not meet Medicare criteria for coverage of the requested items. Therefore, we decided that the Plan 
does not have to pre-approve a RomTech portable connect adaptive rehabilitation device and a remote 
treatment function device.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Prolia provided on August 12, 2021. 
 
You asked the Plan to pay for the Prolia. You say that the infusion of Prolia provided on August 12, 2021, was 
medically necessary. The Plan denied your request. The Plan says that the infusion of Prolia provided on 
August 12, 2021, was not medically necessary. 
 
Please note, the Plan based their denial on Local Coverage Determinations and Articles that are not binding in 
this case as they are not in the correct jurisdiction. 
 
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 pay for the Prolia. Our reviewer says that the 
infusion of Prolia provided on August 12, 2021, was medically necessary. Our physician reviewer found the 
review indicates that the documentation supports that Prolia was medically reasonable and necessary for the 
enrollee. The documentation supports that Prolia was safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Prolia have been met. Therefore, we decided that the Plan has to pay for the 
Prolia provided on August 12, 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.