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

 
We decided that the Plan does not have to waive the copayment for LDCT scan for lung cancer provided on 
July 29, 2022. 
 
You asked the Plan to waive the copayment for LDCT scan for lung cancer. You say that you had a low dose 
CT for lung cancer screening in April, the provider spotted something and requested you to have another one in 
3 months. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 per day 
for Medicare-covered diagnostic radiology services. For qualified individuals, a LDCT is covered every 12 
months. There is no coinsurance, copayment, or deductible for the Medicare-covered counseling and shared 
decision-making visit or for the LDCT. 
 
  You have been asked to pay $100 for LDCT scan for lung cancer. The LDCT scan for lung cancer is covered 
every 12 months. You had one on April 29, 2022, therefore the benefit has been exhausted. This LDCT scan 
for lung cancer falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for LDCT scan for lung cancer provided on July 
29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260). 
 
You asked the Plan to pre-approve semi-electric hospital bed. You say that the requested bed is medically 
necessary. The Plan denied your request. The Plan says while the supplied documentation may support a fixed 
height or even a variable height hospital bed, it does not support the coverage criteria of the local coverage 
determination for a semi-electric hospital bed as the documentation does not indicate that the enrollee requires 
frequent and immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation provided 
indicates that the enrollee has COPD that requires supplemental oxygen. She is noted to be ambulatory, 
although limited by her impaired respiratory function, and able to perform daily activities. She may need a 
hospital bed that allows elevation of the head of her bed, but this does not require a semi-electric hospital bed. 
There is no documentation indicating that the enrollee requires the frequent positioning adjustments 
necessitated to require a semi-electric hospital bed, including significant weakness, inability to independently 
perform pressure relief or at risk for skin breakdown. There is no indication that the enrollee requires special 
attachments that must be fixed to a semi-electric hospital bed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), with any type of 
side rails, with mattress (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 16, 2022, to April 14, 2022. 
 
You asked the Plan to pay for the SNF services. You say that the services which the enrollee required and 
received are coverable under the Medicare act. The Plan denied your request. The Plan says the enrollee elected 
Hospice benefits beginning March 16, 2022. The Plan also says that while on Hospice, SNF benefits are not 
available. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 16, 2022, to April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
11, 2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel you should not be 
responsible for the cost-share applied for the inpatient hospital care. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $150 
copayment per day for days 1-6 and after the 6th day, the plan pays 100% of covered expenses. for inpatient 
hospital care.  
 
You have been asked to pay a $150 copayment per day for days 1-6 and after the 6th day, the plan pays 100% 
of covered expenses. for inpatient hospital care. The total amount you are being asked to pay is $900 ($150 x 6 
days = $900). 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 inpatient hospital care provided from July 
11, 2022, to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this claim should be covered. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 14, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 
0031U, 0032U, and 0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator (64582, C1778, C1767, 
C1787). 
 
You asked the Plan to pre-approve a hypoglossal nerve stimulator. You say that you need this item. The Plan 
denied your request. The Plan says there is no documentation provided that supports you demonstrated CPAP 
failure. In contrast, the provider clearly stated you had significant improvement in sleep architecture after you 
started using CPAP. There is also no documentation that you have intolerance to CPAP nor is there documentation of shared decision making that you are intolerant of CPAP despite consultation with a sleep 
expert. 
 
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve neurostimulation is considered 
medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when the 
beneficiary has documentation that demonstrates CPAP failure (defined as AHI greater than 15 despite CPAP 
usage) or CPAP intolerance (defined as less than 4 hours per night, 5 nights per week or the CPAP has been 
returned) including shared decision making that the patient was intolerant of CPAP despite consultation with a 
sleep expert. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a hypoglossal nerve stimulator have not been met. Specifically, documentation indicated you are 
requesting this device out of convenience, which is not medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve a hypoglossal nerve stimulator (64582, C1778, C1767, C1787).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 3, 2021. 
 
You asked the Plan to pay for the medical services. You say that these medical services were not related to the 
patient's hospice diagnosis, so the Plan should pay for them. The Plan denied your request. The Plan says the 
member was enrolled in hospice on the date of service, so either the hospice or Original Medicare is 
responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion subcutaneous of a cardiac rhythm monitor 
including programming (33285). 
 
You asked the Plan to pre-approve the insertion subcutaneous of a cardiac rhythm monitor including 
programming. You say that this service is medically necessary. The Plan denied your request. The Plan says 
the enrollee has not had any syncopal episodes. 
 
The Plan must follow Medicare rules. Medicare rules say that an implantable recorder (ILR) is used when 
syncope is thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a 
traditional pre-symptom memory look recorder (MLR).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the insertion subcutaneous of a cardiac rhythm monitor including programming have not been met. 
Specifically, there is no indication the enrollee has had any syncopal episodes. Therefore, we decided that the 
Plan does not have to pre-approve the insertion subcutaneous of a cardiac rhythm monitor including 
programming (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing provided on May 3, 2022. 
 
You asked the Plan to pay for the testing services. You say that this test was not for preventative care. The Plan 
denied your request. The Plan says the denial was appropriate. 
 
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 the wound nail panel testing was not billed with a single code as required.  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 respiratory panel testing provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable hospital tray with wheels (E0274). 
 
You asked the Plan to pre-approve the item. You say that this is needed because you have multiple sclerosis. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a portable hospital tray with wheels (E0274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syn one test with cutaneous neuro diagnostics 
pathology testing. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per the reviewed literature, laboratory measurements of alpha-synuclein incerebrospinal 
fluid/salivary extracellular vesicles, and the Syn-One test (cutaneous alpha-synuclein) in particular are 
experimental and investigational for the diagnosis of Parkinson's disease (PD) because the effectiveness of 
these approaches has not been established. The review has determined that the items/services at issue in this 
case are not medically reasonable or necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Syn one test with cutaneous neuro diagnostics pathology testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted nose procedure provided on August 17, 2021. 
 
You asked the Plan to pay for the unlisted nose procedure. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 30999 is unlisted procedure, nose. 
 
We find that CPT code 30999 is not supported in the medical record. Specifically, for an unlisted procedure, 
the procedure note must include specific documentation indicating the procedure billed under the unspecified 
code. While this description was documented in the operate report narrative, this procedure is inclusive to the 
main procedure (code 30468). Based on this information, we decided that Medicare rules for coverage of the unlisted nose procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
unlisted nose procedure provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the requested item is a necessity for you. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for the 
crutch substitute.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the crutch substitute have not been met. Specifically, this item is not a covered benefit of Medicare 
or the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 provided on March 4, 2022. 
 
You asked the Plan to pay for procedure code 97598. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is an add-on code billed without a primary procedure code. 
 
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 
procedure code 97598 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97598 provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are only covered under certain 
medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a medical history including cerebral palsy and profound intellectual 
disability. The documentation indicates the member is non-ambulatory and requires total care. In this case, the 
enrollee is not able to safely or independently use the requested wheelchair, and does not have a caregiver who 
can operate a manual wheelchair. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted lumbar spine surgery with an 
inpatient admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
narrowing of the lumbar spine (spinal stenosis) and ongoing back pain. There is no detailed documentation of 
instability of the lumbar spine, as the x-rays from August 18, 2022 do not note instability. There is no 
documentation of a recent trial and failure of reasonable conservative measures. You are also noted to be a 
current every day smoker with potential for adverse effects on fusion. The surgery and inpatient admission are 
therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve computer-assisted lumbar spine surgery with an inpatient admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360) provided on March 1, 
2022. 
 
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 claim cannot be paid 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 find that CPT codes 88341, 88342, & 88360 are not supported in the medical record. Specifically, the 
billed codes have a professional component / technical component indicator of 1. The services were billed with 
place of service 22 (outpatient hospital). The required 26 modifier was not billed. 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 (88341, 88342, 88360) provided on March 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75571 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 75571. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 75571 is bundled into 
payment for code 75572. 
 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 75571 
is a column II code to column I code 75572. 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 procedure code 75571 billed for date of service July 25, 2022.