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

 
We decided that the Plan does not have to pay for surgical services (37232, 75710) provided May 10, 2021. 
 
You asked the Plan to pay for the surgical 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 37232 & 75710 is not supported in the medical record. Specifically, the operative report 
describes an unsuccessful angioplasty, therefore, an additional vessel cannot be verified. CPT code 75710 is 
not supported. The report does not support this procedure as a separate procedure from the primary, as this 
procedure would be performed for revascularization/endovascular procedure. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (37232, 75710) provided May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the continuous glucose monitor. Our 
reviewer says that the continuous glucose monitor is not medically necessary. Our physician reviewer found 
the records provided do not show that the enrollee uses insulin injections at least 3 times daily.  
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 continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the peripheral blood smear interpretation provided on September 17, 
2021, billed with code 85060. 
 
You asked the Plan to pay for the peripheral blood smear interpretation. You say that this was billed with the 
correct place of service code. The Plan denied your request. The Plan says that the professional/technical 
component flag for this code is 8. This means that no payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital patients. 
 
The Plan must follow Medicare rules. Medicare rules say that the code 85060 is used only when a physician 
interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the hospital 
is responsible for the technical component. 
 
We looked at the file and the Medicare rules. We do recognize that there is conflicting information between the 
rules as cited from the Medicare Claims Processing Manual and the coding information from the Physician Fee 
Schedule. In the hierarchy of authority, citations from Medicare manuals takes precedence over citations from 
coding policies and fee schedules. Because the facility would be paid for the technical component of testing for 
a hospital outpatient, we find that payment of these services with the outpatient hospital place of service is 
appropriate. Therefore, we decided that the Plan has to pay for the peripheral blood smear interpretation 
provided on September 17, 2021, billed with code 85060.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0239U) provided September 2, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this procedure was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Molecular pathology procedures are covered when 
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 
this testing was not medically necessary. Our physician reviewer found documentation does not support that 
the coverage criteria for FoundationOne Liquid CDx testing were met in this case. FoundationOne Liquid CDx 
is used to analyze over 300 genes. The documentation in the case file does not support that alternative 
laboratory or clinical tests to definitively diagnose the condition are unavailable or the results are clearly 
equivocal, and that the number of genes or tests are reasonable and necessary to obtain necessary information 
for therapeutic decision making. 
 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (0239U) provided September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for a specialist office visit (99204) rendered on 
June 1, 2021. 
 
You asked the Plan to reduce the deductible for a specialist office visit. You say that you just realized you paid 
$134.86 for this visit to a "specialist" (urologist) instead of the standard $40 copayment, and the insurance paid 
nothing. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 there is $134.86 toward the $350 deductible which applies to 
physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $134.86 for a specialist office visit. A Specialist office visit falls within the benefit 
category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $350 deductible for all items and services except those 
specifically excluded by the Plan contract. The Plan deductible applies to a specialist office visit.  
 This cost sharing is a contractual obligation that had not been met at the time a specialist office visit was 
received on June 1, 2021. Therefore, we decided that the Plan does not have to reduce the deductible for a 
specialist office visit (99204) rendered on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel (0242U) 
provided on August 29, 2021. 
 
You asked the Plan to pay for code 0242U. 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. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the Targeted genomic sequence analysis panel 
(0242U) provided on August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 1, 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 July 1, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the test for graft blood flow provided on July 7, 2021, billed with code 
15860. 
 
You asked the Plan to pay for the test for graft blood flow. You say that this should be separately paid. The 
Plan denied your request. The Plan says that the operative report clearly shows that this service is inclusive to 
payment for code 44120. 
 
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. The documentation submitted by the Plan is not sufficient to support the denial 
rationale in this case. There is no National Correct Coding Initiative (NCCI) edit which prevents payment of 
15860 when billed with 44120. The Plan's case narrative includes numerous citations to the operative report; 
however, no copy of the operative report is present in the file. As such, a review to determine whether 15860 is 
appropriate for separate payment cannot be completed. Therefore, we decided that the Plan has to pay for the 
test for graft blood flow provided on July 7, 2021, billed with code 15860.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis 0.05%. 
 
You asked the Plan to pre-approve Restasis. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says Restasis is not eligible for coverage under the Part B medical benefit. 
 
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 Restasis 0.05%.  
 
 
 Benefits for Restasis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a computed tomography (CT) scan of 
the head provided on October 11, 2021, billed with code 70450. 
 
You asked the Plan to pay for the CT scan interpretation as billed. You say that this should be paid as multiple 
exams were performed on this date of service. The Plan denied your request. The Plan says this claim was not 
billed with an appropriate modifier. 
 
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 code 70450 
is a column II code to column I code 70496, which was billed by the same billing provider. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of a 
computed tomography (CT) scan of the head provided on October 11, 2021, billed with code 70450.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a penile prosthesis. 
 
You asked the Plan to pre-approve the penile prosthesis. You say that this should be approved due to medical 
necessity. The Plan denied your request. The Plan says the records do not show that this service is medically 
necessary. 
 
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 the penile prosthesis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has erectile dysfunction. The record provided is 
insufficient to establish that the requested service is appropriate for the enrollee's specific clinical 
conditions. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 
 
 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 penile prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a penile prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum suspension system 
(L5781). 
 
You asked the Plan to pre-approve the lower limb prosthesis vacuum suspension system. You say that this 
feature is medically necessary. The Plan denied your request. The Plan says the suspension system is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. 
 
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 lower limb prosthesis vacuum 
suspension system. Our reviewer says that the requested prosthesis is not medically necessary. Our physician 
reviewer found based on the medical records provided there is no clear documentation that the requested 
vacuum assisted suspension system (VASS) meets Medicare criteria for medically necessary for the enrollee. No additional history or physical examination data were provided documenting that the enrollee was 
experiencing edema or volume fluctuations to support the requested 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 the lower limb prosthesis vacuum suspension system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis vacuum suspension 
system (L5781).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested SNF services. 
 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you are ambulating hundreds of feet 
and tending to Activities of Daily Living commiserate with your weight bearing status. Daily skilled services 
are not required to establish a maintenance proram or to prevent deterioration of your condition. Your care 
needs may 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided 
on November 20, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $90 
copayment for Emergency care.  
 
 
 
 
 
 You have been asked to pay a $90 copayment for the emergency room 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 emergency room visit (99283) provided on November 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you received on October 
15, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that this lab work was part of your 
annual physical, so there should be no copayment. You said that your Annual Notice of Change says that there 
is no copay if lab services are performed as part of an office visit. The Plan denied your request. The Plan says 
you were charged this copayment 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 $5 
copayment for lab services. 
  
  
You stated that your Annual Notice of Change says that lab services performed as part of an office visit do not 
have a copayment. However, this lab service was not part of an office visit- it occurred a week after the office 
visit.   In addition, your Plan contract says that an annual physical includes the following services: bodily 
systems examinations, measurement and recording of vital signs, a complete prescription medication review, 
and a review of recent hospitalizations.  It does not include lab services. You have been asked to pay a $5 
copayment for the lab services. 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 the lab services you 
received on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided June 8, 2021. 
 
You asked the Plan to pay for the office visit. You say that this service should be covered by the Medicare 
Advantage plan. The Plan denied your request. The Plan says the primary insurer must issue an explanation of 
benefits before the secondary insurer can process the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for an office visit (99214) provided June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0013M) provided August 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage of code 0013M for CxBladder was 
reaffirmed by Medicare. 
 
We looked at the file and Medicare rules. The service at issue is CxBladder testing. This procedure is non-
covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(0013M) provided August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cologuard test (81528) provided on July 13, 2021. 
 
You asked the Plan to pay for the Cologuard test. 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 effective for dates of service on or after October 
9, 2014, colorectal cancer screening using the Cologuard test (code 81528) is covered once every 3 years for 
asymptomatic Medicare beneficiaries who are 50-80 years of age and are at average risk for developing 
colorectal cancer. The file shows that the enrollee is less than 50 years of age. Based on this information, we 
decided that Medicare rules for coverage of the Cologuard test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cologuard test (81528) provided on July 13, 2021.