Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that medically necessary services were provided 
in good faith. The Plan denied your request. The Plan says there was no documented contact with the primary 
care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The records provided do not indicate the treating physician consulted or 
made an attempt to consult with the enrollees primary physician. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the psychotherapy services provided on August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from May 1, 
2021, to May 4, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you have never been allowed to self-
administer your own drugs in the hospital. The Plan denied your request. The Plan says this claim was 
processed correctly. The Plan also says that the medical portion of your Medicare benefit does not cover self-
administered drugs. 
 
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 pay for the self-administered drugs 
(A9270) provided from May 1, 2021, to May 4, 2021.  
 Benefits for the self-administered drugs 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
12, 2021, to August 16, 2021. 
 
You asked the Plan to pay for home health services. You say that you did not have enough time to submit the 
information. The Plan denied your request. The Plan says you did not submit a RAP within five days of the 
start of service. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from May 12, 
2021, to August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory panel with 22 targets (0202U) provided on 
November 7, 2021. 
 
You asked the Plan to pay for a respiratory panel. You say that this was billed with a payable code. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panel tests for greater than 
5 respiratory pathogens are not medically reasonable and necessary for the purposes of Medicare coverage. 
 
We looked at the file and Medicare rules. The panel at issue had more than 5 targets and is not considered 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a 
respiratory panel have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory 
panel with 22 targets (0202U) provided on November 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for a CPAP device have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires 
objective evidence of adherence to use of the PAP device. Adherence to therapy is defined as use of PAP equal 
to or greater than 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during 
the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, the provided medical documentation does not 
support adherence to therapy. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device (E0601).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography (95811). 
 
You asked the Plan to pre-approve polysomnography. You say that polysomnography is medically necessary 
and appropriate for this enrollee. The Plan denied your request. The Plan says the criteria for coverage of 
polysomnography testing are not met in this case, and therefore this service is denied as 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 polysomnography. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have evidence of prior sleep apnea being present but was 
suspected as having it by the treating physician. However, with an Epworth score of 3 and clear psychological 
cause of insomnia and poor sleep hygiene, there is insufficient clinical evidence or criteria met to justify 
polysomnography 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 polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography (95811).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this service is medically 
necessary as the enrollee was previously diagnosed with breast cancer and is at risk of developing 
lymphedema. The Plan denied your request. The Plan says that the enrollee had a normal L-Dex measurement 
on November 2, 2021. There was no indication of lymphedema. This service is not medically reasonable or 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that Bioimpedance spectroscopy (BIS) for breast cancer related lymphedema 
assessment has become a standard of care for prevention and treatment. Clinical measurements are obtained 
initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes 
during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal 
limb can be performed. BIS has been shown to be superior to standard measurement techniques such as a tape 
measure. Given that the highest risk of developing lymphedema is within the first three years of treatment and 
that early intervention can limit progression of disease, high-risk patients should be followed closely in this 
period. The service is reasonable and medically 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 bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy (BIS) (93702).  
 
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 the genetic testing (81455) provided on June 30, 2021. 
 
You asked the Plan to pay for code 81455. 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 providers must report services correctly. 
 
 
 
 
 
 We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will 
be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing 
(81455) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), provided on September 1, 2020 
 
You asked the Plan to pay for the prophylaxis. You say that the service should be covered. The Plan denied 
your request. The Plan says the benefit for this service has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, records indicate you have already received two cleanings 
for the plan year. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), 
provided on September 1, 2020
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided on November 9, 
2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a preventive 
screening colonoscopy (code G0121). You also say that there was a billing error, and the code was changed to 
a diagnostic colonoscopy. The Plan denied your request. The Plan says that you have been charged the correct 
cost sharing amount. 
 
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 Plan did not provide medical records to show whether the colonoscopy was 
diagnostic or a preventive screening. Therefore, we are unable to determine if cost sharing should be applied. 
Therefore, we decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided on 
November 9, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a knee x-ray provided on October 22, 2021. 
 
You asked the Plan to waive the copayment for a knee x-ray. You say that the x-ray was ordered as part of a 
follow up after having knee surgery. You also say that the doctor's office told you that you should not be 
charged for the x-ray. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $25 
copayment for in and out of network x-ray services.  
 
The record shows that diagnostic radiological procedures are not included in the global surgery payment. You 
have been asked to pay a $25 copayment for a knee x-ray. A knee x-ray 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 a knee x-ray provided on October 22, 2021.  
 
Your complaint about the doctors office telling you that you should not be charged is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on 
July 15, 2021. 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the panel 
does not meet Medicare coverage criteria. 
 
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. 
 
We looked at the file and the rules. The records show that the panel was requested based on personal and/or 
family history of the enrollee. However, there are no medical records provided to show that the testing was 
ordered based on signs or symptoms of a specific medical problem. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive 
cardiovascular gene panel provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated knee orthosis (L1851) and suspension 
sleeve (L2397), provided on October 21, 2021. 
 
You asked the Plan to pay for the prefabricated knee orthosis and suspension sleeve. You say that the items are 
medically necessary. The Plan denied your request. The Plan says these items were obtained through an 
unsolicited telephone call. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
 
 We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the prefabricated 
knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to 
pay for the prefabricated knee orthosis (L1851) and suspension sleeve (L2397), provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care services (procedure code 99223) 
provided to the enrollee from June 7, 2021, to June 12, 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 diagnosis code was not appropriate in this case. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the services were billed with a 
primary diagnosis code of J12.82 - pneumonia due to coronavirus. Medicare follows ICD-10 coding guidelines, 
which has instruction to "code first." J12.82 Pneumonia due to coronavirus would not be reported as the 
primary procedure code as it states it is "due to coronavirus".  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care services (procedure code 99223) provided to the enrollee from June 7, 
2021, to June 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a customized power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a customized power wheelchair. You say that the enrollee relies upon a 
wheelchair to enhance quality of life. The Plan denied your request. The Plan says that the medical records 
indicate the enrollee currently has a power wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. A power wheelchair serves the same purpose as a 
customized power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a customized 
power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (99100) and 
anesthesia complicated by emergency conditions (99140) provided on April 27, 2021. 
 
You asked the Plan to pay for the anesthesia for patient of extreme age (99100) and anesthesia complicated by 
emergency conditions (99140). You say that the digitized anesthesia records should be reconsidered, and 
payment should be submitted. The Plan denied your request. The Plan says bundled services are not eligible for 
separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT 
Code Manual definition of code 99140 is anesthesia complicated by emergency conditions (specify) (List 
separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT codes 99100 and 99140 
have a status indicator of B. This means that CPT codes 99100 and 99140 are considered bundled and not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
for patient of extreme age (99100) and anesthesia complicated by emergency conditions (99140) have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia for patient of extreme age 
(99100) and anesthesia complicated by emergency conditions (99140) provided on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on 
November 13, 2021. 
 
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level 
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so is not separately payable 
without 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. 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 a computed tomography (CT) scan (70450) provided on 
November 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that the testing will guide appropriate medical 
management of the enrollee. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The file shows that a gene panel was provided. We looked at the file and Medicare rules. The claim was billed 
with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. The 
gene panel was also billed with multiple codes. If a single procedure is performed, only one code with one unit 
of service may be reported for the procedure. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on June 20, 2021.